As
an
Equal
Opportunity
Employer,
this
organization
does
not
discriminate
on
the
basis
of
race,
color,
religion,
sex,
national
origin,
age,
disability,
or
veteran
status. All
information
provided
in
this
application
will
be
treated
confidentially
and
will
be
used
only
to
help
ensure
the
best
use
of
your
abilities
if
we
employ
you.
Position
applied
for:
Date
of
application:
How
were
you
referred
to
us?
Newspaper
ad
School
On
my
own
Current
employee
Agency
Other
Name
Address
City
State
Zip Code
Home
Telephone
Business
Telephone
Email
Do
you
wish
to
work:
Full-Time
Part-Time
Temporary
If
part-time,
specify
hours
or
days:
What
is
your
minimum salary
requirement?
Date
available
to
start:
Do
you
have
any
commitments
to another
employer
that
might
affect your
employment
with
us? (If
yes,
please
explain)
NO
YES,
If
you
are
under
18
years
of
age, can
you
provide
required
proof of
your
eligibility
to
work?
NO
YES
Have
you
previously
applied for
employment
here? (If
yes,
please
explain)
NO
YES,
Have
you
previously
been employed
by
this
company? (If
yes,
please
explain)
NO
YES,
Are
any
of
your
relatives employed
here?
(If
yes,
please
list
name
and
department)
NO
YES,
Are
you
a
United
States
citizen?
NO
YES
If
not,
are
you
prevented
from becoming
lawfully
employed
in this
country
because
of visa
or
immigration
status?
(Proof
of
citizenship
or
immigration status
will
be
required
upon employment.)
NO
YES
Are
you
able
to
perform
the essential
functions
of
the
job for
which
you
are
applying?
NO
YES
Have
you
been
convicted
of
a felony
within
the
last
7
years?
NO
YES
If
yes,
Please
explain
nature: (An
affirmative
answer
will
not automatically
disqualify
you
from being
considered
as
a candidate
for
employment.)
1
The
most
important
attributes that
I
bring
to
the
job
are:
2
A
position
that
best
fits
me
is:
3
When
under
pressure
I:
Former
Employers(List
last
three
employers,
starting
with
last
one
first.) (List
employer
name,
address,
salary
, position
and
reason
for
leaving.)
Education
-
High
School (List
name,
location,
years
attended, graduation
date
and
subject
studied)
Education
-
College (List
name,
location,
years
attended, graduation
date
and
subject
studied)
Education
-
Trade,
Business,
or Correspondence
School
(List
name,
location, years
attended,
graduation date, and
subject
studied)
References
-
List
name
and
telephone number
of
three
business/work references
who
are
not
related
to you
and
who
are
not
previous supervisors. If
not
applicable,
list three
school
or
personal
references who
are
not
related
to
you.
I
hereby
affirm
that
the
information
provided
on
this
application
(and
accompanying
resume,
if
any)
is
true
and
complete
to
the
best
of
my
knowledge.
I
also
agree
that
falsified
information
or
significant
omissions
may
disqualify
me
from
further
consideration
for
employment,
and
may
be
considered
justification
for
dismissal
if
discovered
at
a
later
date.
I
authorize
person(s),
schools,
my
current
employer
(if
applicable),
and
previous
employers
and
organizations
named
in
the
application
(and
accompanying
resume,
if
any)
to
provide
any
relevant
information
that
may
be
required
to
arrive
at
an
employment
decision,
and
release
all
parties
from
all
liability
for
any
damage
that
may
result
from
furnishing
same
to
you.
This
application
is
not
a
contract
and
cannot
create
a
contract. I
understand
that
my
employment
can
be
terminated
with
or
without
cause,
at
any
time,
at
the
discretion
of
either
the
company
or
myself. I
understand
that
no
management
official,
other
than
the
Chief
Executive
Officer
of
the
company,
has
any
authority
to
enter
into
an
agreement
contrary
to
the
foregoing,
or
make
any
oral
assurance
or
promise
of
continued
employment.
I
understand
this
application
will
be
kept
in
the
active
files
for
a
period
of
six
months
from
the
date
indicated
below. I
further
understand
that
if
I
am
not
hired
during
that
period,
I
must
complete
and
execute
a
new
application
form
to
be
considered
for
future
employment.
