Application for Employment

APPLICATION FOR EMPLOYMENT

At

Employers use this form to determine if an applicant is qualified for the job.

NOTICES TO JOB APPLICANT

EQUAL OPPORTUNITY. It is the policy of the Company to make all employment decisions without regard or consideration for any individual's race; religious creed; color; national origin; ancestry; physical disability (including HIV and AIDS); mental disability; medical condition (meaning cancer or genetically-related disease or disorder); marital status; sex (gender); sexual orientation; gender identity; age (meaning over 40); or pregnancy, childbirth, related medical conditions, or any other factor protected from discrimination by federal, state or local laws.

AT-WILL EMPLOYMENT. Employment at the Company is at the will of the Company and the employee.

Optional Conditions

Physical Exam

Drug Test

Alcohol Test

Driver’s License and DMV Printouts

Licensing

Credit Check / Background Investigation

Right to Work in U.S.

Handbook

Applicant Information

First Name: Middle Name: Last Name:

Street Address: City: State: Zip:

Mailing Address: City: State: Zip:

Other Names Used:

Home Phone: Work Phone: Cell Phone:

Position Applying For:

Can you provide proof of your legal right to work in the U.S.? Yes No

Are you at least 18 years old? Yes No

If no, can you provide proof of your legal authorization to work as a minor? Yes No

Have you ever been convicted by any court of a criminal offense? Yes No

Have you ever received a Dishonorable Discharge from the armed services? Yes No

Are you currently out on bail or on your own recognizance pending a trial? Yes No

If applying for a driving position, has your driver’s license ever been suspended or revoked? Yes No

Have you ever worked here before? Yes No

If yes, list dates:

Date first available for work: Asking wage:

How did you learn about us? Ad Walk-In Employment Agency Referred by

Employment Experience — List your present or last job and go backwards.

Explanation of Gaps in Employment

Explanations of Terminations

Prior Addresses — Please list your prior places of residence for the past 5 years.

1. City: State:

2. City: State:

3. City: State:

Education — List your education, starting with high school.

Language Skills — Optional.

Language 1: Speak Fluent Read Fluent Write Fluent Speak Good Read Good Write Good Speak Fair Read Fair Write Fair

Language 2: Speak Fluent Read Fluent Write Fluent Speak Good Read Good Write Good Speak Fair Read Fair Write Fair

Special Skills and Qualifications

Job Limitations

Job Description is attached Job description is NOT attached

Schedule Availability

Full Time — I am available and desire to work full-time (35-40 hours).

Part Time — I am available and desire to work part-time (less than 35 hours).

Work schedule restrictions:

Comments:

Relatives and Friends — List the names of all relatives and friends currently working for us.

References — Please provide three references that can provide information about your work skills and work habits.

Separate Authorization for Release of Information and Waiver of Potential Claims

I am applying for a job at located at and whose phone number is .

I hereby authorize the Company to contact references, past employers, schools, and training institutions listed in the Employment Application and/or resume.

I hereby waive any potential claim against any references, past employers, schools, and training institutions listed in my Employment Application and/or resume for providing information to the Company.