Equal access to programs, services and employment opportunities is available to all persons without regard to race, color, religion sex (including pregnancy), national origin, age, handicap, disability, marital status, sickle cell trait, genetic information, or any other basis protected by federal, state, and/or local law. In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process• providing written materials in an alternate format such as braille, large print, or audio recording; using a Sign language interpreter; using specialized equipment,• or modifying testing conditions.

Best time to call you

Home Cellular/Other

May we contact you at work?

If yes, work number

Best to call

If you are under 18 and it is required, can you furnish a work permit?

If No, please Explain

Have you submitted an application here before?

If yes, give date(s) and position(s)

Is this application a request for reemployment following an extended military leave of absence from this company?

If yes, additional information may be requested.

Are you lawfully authorized to work in the United States?

Date available for work

Desired salary range or hourly rate of pay? ($)

Per

Type of employment desired

Will you relocate if job requires it?

Will you travel if job requires it?

If they have been explained to you, are vou able to meet the attendance requirements of the position?

Will you work overtime if required?

If no, please explain

This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accomodation)?

Driver's license number

Driver's license state

NOTE: Answering "yes" to this question or the next does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. You are not obligated to disclose sealed or expunged records of conviction or arrest.

Have you ever been bonded?

Have you ever pleaded guilty or no contest to or been convicted of a crime?

If yes, please provide date(s) and details

Have vou ever been a defendant in a civil action for an intentional tort (e.g., a civil charge for assault, battery; intentiona of emotional distress, false imprisonment, wrongful death, etc.)?

If yes, please provide nature of the tort and disposition of the matter (how it was resolved).

Have you entered into an agreement with any former employ er or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?

If yes, please explain

Starting with your most recent employer, provide the following information.

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Explain any gaps in your employment, other than those due to personal illness, injury, or disability.

If not addressed on previous page, have you ever been fired or asked to resign from a job?

If yes, please Explain

Summarize any special training, skills, languages, licenses, and/or certificates that may assist you in performing the position for which you are appllying

Word Processing

Level

Spreadsheet

Level

Presentation

Level

E-mail

Level

Internet

Level

Other

Level

Other

Level

Other

Level

Starting with your most recent school attended, provide the following information.

List names and telephone nuymbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Name

Title

Relationship to you

Telephone

E-mail

# of years known

---

Name

Title

Relationship to you

Telephone

E-mail

# of years known

---

Name

Title

Relationship to you

Telephone

E-mail

# of years known

When answering these questions, please exclude any information that would reveal race, color, religion, sex (including pregnancy), national origin, age, handicap, disability, marital status, sickle cell trait, genetic information, or other similarly protected status. To what job-related organizations (professional, trade, etc.) do you belong?

List special accomplishments, publications, awards, etc.

List any relevant volunteer work.

Is there any other job-related information you want us to know about you?

I certify that ail information I have provided in order to apply for and secure work with this employer is true, completer, and correct.

I expressly authorize without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional) employers, public agencies, licensing and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resumé, or job interview. I hereby waive any rights and claims I may have regarding the employer, its agents, employees. or representatives, for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and question on this application is used for the purpose of limiting or eliminating any applicant from consideration, of employment on any basis prohibited by applicable local, state, or Federal law.

I understand that this application remains current for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cense and with or without prior notices and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative other employer is authorized to make any assurances to the contrary and that implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I understand that if am hired, my employment will be subject to a probationary period: which ordinarily will not exceed 90 days from the date am hired. If I am discharged at any during probationary period for unsatisfactory performance, I understand that this employer will not be charged for any unemployment benefits that may be paid to me work performed during the probationary period.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.

I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer's affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate, or third party is to be used solely to perform the services requested by the employer.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her race, color, religion, sex (including pregnancy), national origin, age, handicap, disability, marital status, sickle cell trait, genetic information, or any other protected status under applicable federal, state, or local law.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

 

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

* Signature of Applicant

* Date