Job Application

* First Name:

* Last Name:

* Address:

Address Line 2:

* City:

* State:

* ZIP:

* Phone:

* email:

* Date of Birth:

* Social Security Number:

* Drivers License Number:

* Drivers License State:

* Expiration Date:

* What date are you available to begin work?

* How many hours per week are you available to work?

* What days are you NOT available to work?

* What is your desired hourly pay?

* Have you ever been employed with this company before?

If Yes, when?

* Do you have any friends or relatives employed by this company?

If Yes, please provide their names and relationship to you:

* Are you currently employed?

May we contact your employer?

* Are you currently on “lay off” status and subject to recall?

If you are under 18 years of age, can you provide proof of your eligibility to work?

* If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?

* Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation?

* If hired, are there any accommodations the company would need to provide so that you can perform all those essential functions and duties of the position being applied for?

If Yes, please explain:

* If driving is a requirement of the position applied for, have you in the last 7 years been convicted of Driving Under the Influence “(DUI)”?

* If hired, do you have a reliable means of transportation to and from work?

* If hired, would you be able to travel or work overtime as needed?

* Have you ever been convicted of a felony or misdemeanor?

If yes, please explain:

Please copy/paste your resume into the space below. If you do not have a resume, please skip to the next question.

* Employed from:

* Employed Until:

* Supervisor Name:

* Supervisor Phone Number:

* Employer Address:

* Starting Salary:

* Ending Salary:

* Job Title:

* Duties & Responsibilities:

* Reason for leaving:

* Are you eligible for re-hire?

Employed from:

Employed Until:

Supervisor Name:

Supervisor Phone Number:

Employer Address:

Starting Salary:

Ending Salary:

Job Title:

Duties & Responsibilities:

Reason for leaving:

Are you eligible for re-hire?

Employed from:

Employed Until:

Supervisor Name:

Supervisor Phone Number:

Employer Address:

Starting Salary:

Ending Salary:

Job Title:

Duties & Responsibilities:

Reason for leaving:

Are you eligible for re-hire?

Employed from:

Employed Until:

Supervisor Name:

Supervisor Phone Number:

Employer Address:

Starting Salary:

Ending Salary:

Job Title:

Duties & Responsibilities:

Reason for leaving:

Are you eligible for re-hire?

Equal Employment Opportunity Statement: This company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. The Company desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, age or any other status protected by Federal, State or local laws. The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the company.

Discrimination and Sexual Harassment Policy Statement: This Company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual’s employment; (2) Submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment.

Disclosure to Applicants Concerning Drug/Alcohol Testing: If you are offered a position with the Company, you may be given a drug/alcohol test as a condition of employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this company. Neither the collector of specimens nor the medical professional who reviews the test results will be a company employee. The test results will be kept confidential. The individual undergoing testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen. Negative test results are required as a condition of employment.

Complete and Accurate Information: I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

At-Will Employment: I understand and agree that if I am employed, my employment will be “at-will”, which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the Company will respect my right to terminate my employment at any time, with or without cause and with or without notice. I further understand that any prior representation, whether expressed or implied to the contrary is hereby superceded and that no promise or representation contrary to the foregoing is binding on the Company unless made in writing and signed by the Company’s president.

Testing Authorization: If offered a position with the Company, I hereby agree to any legally permitted physical, psychological, skill, drug or medical test required by the Company as a condition of employment.

Investigation Authorization: I authorize investigation into all statements and references contained in this application. Said investigation may include credit, driving, criminal background, references and other background checks. By applying for this job, I also authorize post-hire investigation into my credit, driving and criminal background.

Company Obligation: I understand and agree that the Company’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the Company is under no obligation to hire me as the result of accepting this completed application.