NAME:           LAST   FIRST   M.I.               ADDRESS:             STREET   CITY   STATE   ZIP                   MAILING ADDRESS:             PO BOX   CITY   STATE   ZIP                   PHONE NUMBER:           AREA                         EMERGENCY CONTACT:           NAME   PHONE               REFERRED BY? ARE YOU 18 OR OLDER? YES NO EMPLOYMENT DESIRED: POSITION:   DATE YOU CAN START   SALARY DESIRED                     ARE YOU EMPLOYED NOW? YES NO MAY WE CONTACT YOUR EMPLOYER? YES NO             EVER APPLIED TO THIS COMPANY BEFORE? YES NO WHEN?           EDUCATION   NAME & LOCATION OF SCHOOL CHECK LAST YEAR COMPLETED DID YOU GRADUATE SUBJECTS STUDIED AND DEGREE(S) RECEIVED GRAMMAR SCHOOL   Yes No           HIGH SCHOOL 9 10 11 12 Yes No           COLLEGE 1 2 3 4 Yes No           TRADE, BUSINESS, CORRESPONDENCE SCHOOL 1 2 3 4 Yes No GENERAL SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK:  Job related skills or distinctions (Typing, computer skills, Drivers license)  FORMER EMPLOYER DATE MONTH AND YEAR NAME AND ADDRESS OF EMPLOYER SALARY (UPON LEAVING POSITION   YEARS ACQUAINTED FROM     TO       FROM     TO       FROM     TO       REFERENCES NAME PHONE NUMBER POSITION YEARS ACQUAINTED                   IF YOU ARE TO BE HIRED BY THE COMPANY, YOU WILL BE REQUIRED TO ATTEST TO YOUR IDENTITY AND EMPLOYMENT ELIGIBILITY, AND TO PRESENT DOCUMENTS CONFIRMING YOUR IDENTITY AND EMPLOYMENT ELIGIBILITY. YOU WILL NOT BE HIRED IF YOU CANNOT COMPLY WITH THESE REQUIREMENTS. AUTHORIZATION I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION (AND ACCOMPANYING RESUME, IF ANY) ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.  I UNDERSTAND THAT ANY FALSE STATEMENT, OMISSION, OR MISREPRESENTATION ON THIS APPLICATION IS SUFFICIENT CAUSE FOR REFUSAL TO HIRE, DISMISSAL IF I HAVE BEEN EMPLOYED, REGARDLESS OF WHEN DISCOVERED BY THE COMPANY. I UNDERSTAND THAT ANY EMPLOYMENT IS CONDITIONED ON A BACKGROUND CHECK.  I AUTHORIZE THE COMPANY TO THOROUGHLY INVESTIGATE ALL STATEMENTS CONTAINED IN MY APPLICATION OR RESUME, AND I AUTHORIZE MY FORMER EMPLOYERS TO DISCLOSE INFORMATION REGARDING MY FORMER EMPLOYMENT, CHARACTER AND GENERAL REPUTATION TO THE COMPANY, WITHOUT GIVING ME PRIOR NOTICE OF SUCH DISCLOSURE.  IN ADDITION, I RELEASE THE COMPANY AND FORMER EMPLOYERS AND ALL REFERENCES LISTED ABOVE FROM ANY AND ALL CLAIMS, DEMANDS OR LIABILITIES ARISING OUT OF OR RELATED TO SUCH INVESTIGATION OR DISCLOSURE. IF I AM OFFERED EMPLOYMENT I AGREE TO SUBMIT TO A MEDICAL EXAMINATION AND DRUG TEST BEFORE STARTING WORK. IF EMPLOYED, I ALSO WILL SUBMIT TO A MEDICAL EXAM OR DRUG TEST AT ANY TIME DEEMED APPROPRIATE BY THE COMPANY AND AS PERMITTED BY LAW. I CONSENT TO SUCH EXAMINATIONS AND TESTS, AND I REQUEST THAT THE EXAMING DOCTOR DISCLOSE TO THE COMPANY THE RESULTS OF THE EXAMINATIONS, WHICH RESULTS SHALL REMAIN CONFIDENTIAL AND SEGREGATED FROM MY PERSONNEL FILE. I UNDERSTAND THAT MY EMPLOYMENT OR CONTINUED EMPLOYMENT, TO THE EXTENT PERMITTED BY LAW, IS CONTINGENT UPON SATISFACTORY MEDICAL EXAMINATIONS AND DRUG TESTS, AND IF I AM HIRED A CONDITION OF MY EMPLOYMENT WILL BE THAT I ABIDE BY THE COMPANY’S DRUG AND ALCOHOL POLICY. I UNDERSTAND THAT BY FILLING IN THIS FORM DOES NOT INDICATE THERE IS A POSITION OPEN AND DOES NOT OBLIGATE THE COMPANY TO HIRE.  IF HIRED, I AGREE TO ABIDE BY ALL COMPANY WORK RULES, POLICIES AND PROCEDURES.   THE COMPANY RETAINS THE RIGHT TO REVISE ITS POLICIES OR PROCEDURES, IN WHOLE OR IN PART AT ANY TIME. SIGNATURE________________________________________                DATE_______________   Career Opportunities