APPLICATION FOR EMPLOYMENT

FEDERAL LAW PROHIBITS DISCRIMINATION ON THE BASIS OF RACE, COLOR, RELIGION, SEX OR NATIONAL ORIGIN, AS WELL AS DISCRIMINATION ON THE BASIS OF AGE AGAINST PERSONS BETWEEN THE AGE OF 40 AND 65 INCLUSIVE, FEDERAL REGULATIONS ALSO PROHIBIT GOBERNMENT CONTRACTORS FROM DISCRIMINATION ON THE BASIS OF DISABILITY, SOME STATE AND CITY LECISLATION PROHIBITS DISCRIMINATION BECAUSE OF AGE, HANDICAP, MARTAL STATUS, SEXUAL PREFERENCE, RACE, COLOR, RELIGION, SEX OR NATONAL ORIGIN, CONSULT COMPETENT COUNSEL FOR FURTHER INTERPRETATION.

PERSONAL

First Name:

Middle Name:

Last Name:

Street and number:

Social Security No.:

City/State:

ZIP:

Telephone No.:

How many addresses have you had in the last 5 years?

How did you find out about this job?

Newspaper

Referral

Other

Driver License #

State Issued

Expiration Date

If hired, do you have a reliable means of transportation to get to work?

Yes

No

Do you smoke?

Yes

No

Salary desired

Least acceptable salary

Are you a US citizen?

Yes

No

If no, do you have the legal right to work in the US (ie, green card)

Yes

No

Are you at least 16 years old?

Yes

No

EMPLOYMENT DATA

EDUCATION

Elementary

High School

Name and City

College

Name and City

Degree & Major

If currently in high school, are you enrolled in a recognized co-op program: (such as DE, CVA, VOE)

Yes

No

If yes, identify program and school

MILITARY SERVICE

Are you a veteran?

Yes

No

If yes, give dates of service

From

To

Special skill or training

WORK HISTORY

Please list your last 4 employers. Begin with the most recent employer

1.

Company

Address

Phone

From

To

Job Title

Reason for Leaving

Supervisor's Name and Title

Describe Duties Briefly

Starting Salary

Ending Salary

2.

Company

Address

Phone

From

To

Job Title

Reason for Leaving

Supervisor's Name and Title

Describe Duties Briefly

Starting Salary

Ending Salary

3.

Company

Address

Phone

From

To

Job Title

Give specific reason for leaving

Supervisors name and title

Describe duties briefly

Starting salary

Ending salary

4.

Company

Address

Phone

From

To

Job Title

Give specific reason for leaving

Supervisors name and title

Describe duties briefly

Starting salary

Ending salary

Describe duties briefly

Starting salary

Ending salary

May we contact the employers listed above?

Yes

No

If not, tell us which one(s) you do not wish us to contact and why.

How many jobs have you had in the last 10 years that are not listed above?

Why are you seeking a new position at this time?

What is the job you have enjoyed most and why?

List any outside interests including organizations you're active in that are business related

Bonding and money handling security policies require that we ask if you have ever been convicted of a felony

Yes

No

On parole

Yes

No

Or awaiting trial

Yes

No

If yes, state the nature of the offense and disposition of the case. Include dates and places: NOTE: Felony convictions or the existence of a criminal record does not constitute an automatic bar to employment

I authorize this company to make an investigation of all information contained in this application for employment, and I release from all liability all companies and corporations supplying such information. I understand that any false answers, statements or implications made by me on this application or other required documents shall be considered sufficient cause for denial or employment or discharge. Upon termination of my employment for whatever reason, | release this company from all liability for supplying any information concerning my employment to any potental employer. I authorize this company to request a copy of my credit report from the Credit Bureau, a copy of my motor vehicle driving record, if applicable. I hereby agree lo submit to such physical examination(s) as may be required and any drug test(s) that may be requested of me, whether prior to my employment or, if employed by this company, at any time thereafter. During such employment, I understand and agree that in the event that I receive medical treatment for any condition, including a physical, psychological, emotional, or paychiatric condition, I hereby authorize the limited release and exchange of medical information relating to my condition bebween the treatment provider and a company designated physician. I further understand that this is an applicaiton for employment and that no employment contract is being offered. I understand that if I am employed, such employment is for an indefinite period of time and that the company can change wages, benefits and conditions at any time. I have read and understand the above.

Applicant's Signature

Date