Employment Application - 9/5/2008

General Information
(All fields in red must be completed to insure correct processing of your application)

First Name:
Middle Name:
Last Name:
Current Address:
City: State: Zip:
Social Security Number:
Home Phone: Business Phone:
Cellular Phone or Pager:
Driver's License #: License State:
Email Address:
Emergency Contact: Contact Phone:
Position Applied for: Minimum Annual Salary: (Enter Numbers Only)
Other Positions Desired:
Are you Employed Now: Yes No
If so, may we inquire of your present employer: Yes No
Date you can start: (mm/dd/yyyy)

Have you ever applied before? Yes No
What Position?
If so, when? (mm/yyyy)
Have you ever worked here before? Yes No
What Position?
If so, when? (mm/yyyy)
Are you able to relocate? Yes No

Type of Employment Desired: Full Time Temporary
Are you available to work any shift? Yes No
Are you available to work weekends? Yes No
Will you work overtime if asked? Yes No
Can you travel if job requires it? Yes No
Are you at least 18 years of age? Yes No
(if you are under 18 years of age, you must provide required proof of your eligibility to work)
Are you a US Citizen? Yes No
If not, are you authorized to work in the USA? Yes No
Citizenship (All persons, upon hiring, must verify citizenship status or provide valid authorization to work in the U.S.)
Have you ever been convicted of a felony? Yes No
(A conviction will not automatically disqualify you from employment)
If yes, state the offense, location, date and disposition:

Do you have friends or Relatives who work for the company? Yes No
If so, Who?
How did you hear about the position?

Educational Background
High School:
Location:
Years Completed:
Did you receive a diploma? Yes No

College:
Location:
Years Completed:
Course(s) of study:
Did you receive a degree/diploma? Yes No

Business/Trade/Technical School:
Location:
Years Completed:
Course(s) of study:
Did you receive a degree/diploma? Yes No

Military Branch:
Rank:
Duties:
Years Served:
Course(s) of study:

Other:
Location:
Years Completed:
Course(s) of study:
Did you receive a degree/diploma? Yes No

Specialized Skills - Select any that apply
Access Data Entry Innovative Software Microsoft Word Report Writer
AS/400 System Infinium Software Microsoft Excel Powerpoint Typing WPM

Specialty Equipment (list):

Additional Qualifications/Skills/Knowledge

Employment History
Most Recent/Current Company Name:
From: (mm/dd/yyyy) To: (mm/dd/yyyy)
Telephone Number:
Address:
City:
State:
Zip Code:
Name of Supervisor: May we contact? Yes No
Starting Pay: End Pay:
Job Title and Description of Duties:

Reason for Leaving:

Company Name:
From: (mm/dd/yyyy) To: (mm/dd/yyyy)
Telephone Number:
Address:
City:
State:
Zip Code:
Name of Supervisor:
Starting Pay: End Pay:
Job Title and Description of Duties:

Reason for Leaving:

Company Name:
From: (mm/dd/yyyy) To: (mm/dd/yyyy)
Telephone Number:
Address:
City:
State:
Zip Code:
Name of Supervisor:
Starting Pay: End Pay:
Job Title and Description of Duties:

Reason for Leaving:

References: Please list co-workers or supervisors who can comment on your work performance

Name:
Phone:
Company:
Years Acquainted:

Name:
Phone:
Company:
Years Acquainted:

Name:
Phone:
Company:
Years Acquainted:

Name:
Phone:
Company:
Years Acquainted:

Name:
Phone:
Company:
Years Acquainted:

*PLEASE READ CAREFULLY BEFORE SUBMITTING*

I certify that all information included in this application is correct and complete. I understand that falsification or omission on any part of this application form and/or attached resume or credentials, including any information submitted via electronic means, may result in denial of employment or if employed, dismissal, regardless of when discovered.

This is to notify you that a Consumer Report and/or Investigative Consumer Report will be conducted on you for employment purposes.

By signing the release below, I hereby authorize the Company to contact any and all corporations, former employer�s, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts, military services to release information about my background including, but not limited to, information about employment, education, consumer credit history, driving record, criminal record and general public records history to the Company.

I release from all liability all persons, companies, schools supplying such information. I indemnify the Company against any liability, which may result from making such requests. This release shall remain in effect for the length of my employment.If hired, I understand that I may have a right to request additional disclosures regarding the nature and scope of the investigation. I also understand that I will be given a copy of the consumer report and a written description of my rights under the Fair Credit Reporting Act.

A copy of this application, including FAX transmissions, shall be considered as effective and valid as the original. By my submission of this application, I have read, understand and agree with this statement

I understand that any employment relationship which might be established between me and the Company will be one of an �at will� nature and in which either the Company or I will be free to terminate at any time, with or without cause. Such �at will� status is not subject to change unless such change is specifically acknowledged in writing and signed by the President of the Company.

I understand that if my employment is terminated, whether by the company or on my own accord, I give my permission to the Company to provide information regarding my employment history, drug and alcohol results, etc. to other Companies. I release all parties involved in these reference checks from any and all liability for any and all damage that may result from providing such information.