Application for Employment
(an Equal Opportunity Employer)

Name   Date

Present Address

Phone Number   Are you 18 years or older No Yes

Are you either a U.S. citizen or an alien authorized to work in the United States? No Yes

Height    Feet Inches

Weight   lbs

Date of Birth

Have you been convicted of a felony or misdemeanor within the last 5 years No Yes

If yes describe

Employment Desired

Position   Date you can start   Salary Desired

Are you employed now? No Yes    If so may we inquire of your present employer? No Yes

Ever applied to this company before? No Yes    When?

U.S. Military or Navel Service Rank

Present Membership in National Guard or Reserves

References

Physical Record

Do you have any physical limitations that preclude you from performing any work for which you are being considered? No Yes

If yes, what can be done to accommodate your limitations?

In case of emergency notify

Name

Address

Phone

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and pertinent information they may have personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that if hired my employment is for no definite period and may regardless of the date of payment of my wages and salary be terminated at any time without prior notice.”