* = Required Information

Name (Last, First, Middle Initial)

Present Address (Street, City, State, Zip)

Social Security #

Home Phone #

Alternate Phone #

Position For Which You Are Applying

Starting Rate Required $per hour

Check All That Apply:

Full-time

Part-time

Weekends

Overnight

What shifts would you prefer?

Morning

Afternoon

Evening

Whom Were Your Referred?

Are You At Least 18 Years of Age?

YesNo

This Company will only work with U.S. Citizens and Aliens Lawfully Authorized to Work in the U.S. Are you a U.S. Citizen?

YesNo

If not a U.S. Citizen, are you lawfully authorized to work in the U.S.?

YesNo

If yes, please explain

Are you capable of performing, with or without reasonable accommodation, the essential functions of the job for which you have worked?

YesNo

List below 3 past employers, including current, beginning with your most recent, including military service:

Company Name and Address

Title

Phone #

Type of Business

Duties

Starting Salary

Ending Salary

From (Month/Year)

To (Month/Year)

Name of Supervisor(s)

Reason For Leaving

Company Name and Address

Title

Phone #

Type of Business

Duties

Starting Salary

Ending Salary

From (Month/Year)

To (Month/Year)

Name of Supervisor(s)

Reason For Leaving

Company Name and Address

Title

Phone #

Type of Business

Duties

Starting Salary

Ending Salary

From (Month/Year)

To (Month/Year)

Name of Supervisor(s)

Reason For Leaving

May we contact employers listed above?

YesNo

If not, indicate which one(s) you do not wish us to contact:

If your school records are under a different name, please enter that name:

High School (Name and Address)

Years Completed

Did you graduate?

YesNo

College (Name and Address)

Years Completed

Did you graduate?

YesNo

List diploma or degree

Course of Study (major/minor)

Other (Name and Address)

Years Completed

Did you graduate?

YesNo

List diploma or degree

Are you attending school or taking courses now?

YesNo

If yes, where?

List scholastic honors

Do you have an appropriate valid driver's license?

YesNo

Driver's License #

In the past three years have you received any moving violations or been involved in any vehicular accidents that were your fault?

YesNo

If so, please explain:

Do not refer to relatives, include only individuals familiar with your work ability

Name	Address (Street, City, State, Zip)	Years Known	Occupation

REMARKS

I certify that the facts contained in this application are true and complete. I understand that falsified statements on this application will be considered cause for discharge.

I further acknowledge and agree that my contract may be terminated, with or without prior notice, at any time, at the will of the company or me, with or without cause.

The representative or employee of the Company, with the exception of the Agency Director/Owner, has the authority to enter into any contract or statement to the contrary, and then only if such commitment is in a written document signed by the Agency Director/Owner and the employee.

This application will be maintained in the Company's active files for three months only, unless renewed.

I acknowledge that I have read and understand these terms:

PRINTED NAME *

Signature