Position applying for (select one)
May 25, 2013, 10:02 pm
I was referred by: (only one)
Word of mouth
Who or Where?
An equal opportunity employer. Applicable Law & company policy prohibits discrimination based on race, religion, color, age, sex, national orgin or physical disability.
Main Contact Number
Number & Street
2nd Contact Number
(if less than 2 years at present address)
Age 18 or older
Statement of Availability
Please indicate the days and hours you are available to work.
check each day
you can work
I am available
to work from
Please account for all employment over the past five years - include military service.
Most Recent First
Company Name, Address &
Reason For Leaving
Personal or Business References
Give names of three persons (excluding relaives) familiar with your work performance that we may contact.
# Yrs. Known
Education and Training
Name & Location of School
Course of Study
Upload Your Resume
Work Eligibility Status
Have you ever been previosly employed by this company? Yes
If yes, Where:
Have you ever been convicted of a crime? Yes
If yes, please explain below
Are you legally eligible to work in the United States? Yes
If you are NOT a U.S. citizen, list type of Visa held:
Document Number -
In Case of Emergency, Please Notify
I declare that all statements and answers given in this application are true and complete. I understand and agree that any untruth, misleading answer, omission, concealment or failure to answer any question fully, completely and accurately will be grounds for terminating my employment.
I authorize the Employer and any Company agent to investigate my references, to communicate with my former employers concerning the same, and to make an independent investigation of my character, conduct and employment record and to keep and preserve records of such investigation.
If employed I agree to read and comply with all company rules, regulations and policies. Further, I agree that upon termination of my employment I will return all company property and materials in my possession.
I agree to submit to a physical examination if requested by Employer. Employer shall designate the physical and shall also pay the examination expense. A physical examination may be requested prior to accepting employment or at any subsequent intervals after employment is granted. The purpose of such examination (or examinations) will determine my physical fitness to begin or continue employment with Employer.
I agree that if employment is offered and accepted by me, it is mutually understood that any employment with this organization is of an “at will” nature and is not confined to a fixed term which means that I may resign at any time and the Employer may discharge me at any time with out prior notice, with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is acknowledged in writing by an authorized executive of this Company.
I understand Federal Law prohibits employment of unauthorized aliens. All persons hired must submit proof of employment authorization. Failure to submit such proof within required time will result in immediate termination.
*if you agree to the above