Please provide the following information:

First Name
Last Name
Street Address
Address (cont.)
City, State, Zip
Home Phone
E-mail

Position applied for or type of work desired:

Date available to work: Shifts available to work:

Wage Requirement:

Have you ever been previously employed by this company? Yes  No

Can you submit proof of legal employment authorization and identity? Yes No

Are you 21 years of age or older? Yes No

Have you been convicted of a crime in the last 7 years? Yes No
If yes, please explain. (Do not include traffic tickets. Note: Conviction of a crime or crimes will not necessarily disqualify you from employment.)

Have you ever been discharged or asked to resign? Yes No
If yes, please explain:

Have you ever been in the military? Yes No
If yes, please describe the skills you acquired:

Do you have means for getting to work regularly? Yes No

Please list any languages other than English you can read, write, or speak:

If an offer of employment is made, and prior to your commencement of employment duties, you may be required to undergo a medical examination and/or drug test, the results of which may affect the offer of employment. Are you willing to undergo such an examination? Yes No

I hereby authorize the company to contact, obtain and verify the accuracy of information contained in this application from all previous employers, educational institutions and references.  I also hereby release from liability the company  and its representatives for seeking, gathering and using such information to make employment decisions and all other persons or organizations for providing information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment.  Accordingly, either I or the company can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of the company not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA.

I understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired.  Failure to submit such proof within the required time shall result in immediate termination of employment.

By completing and signing this application, I understand and agree to submit to drug and alcohol testing as provided for in the organization's drug and alcohol policy.

I represent that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Applicant's Signature:_________________________________ Date:___________________
(you will sign this in person)

ATTENTION APPLICANT: 
This application will be kept under active consideration for no more than 30 days from the date of application.

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