MY LIFE LLC

MY LIFE LLC
APPLICATION FOR EMPLOYMENT
My Life LLC is an equal opportunity employer and does not discriminate against any applicant or employee on the basis of race, color, religion, sex, pregnancy, sexual orientation, gender identity, age, ancestry, national origin (including language proficiency), genetic information, marital status, disability, military service, veteran status, qualified disabled veteran status or any other characteristic protected by applicable law. Please answer all questions as completely as possible. YOUR APPLICATION WILL BE CONSIDERED ACTIVE FOR THIRTY (30) DAYS. FOR CONSIDERATION AFTER THAT DATE YOU MUST REAPPLY. We encourage applications from qualified individuals with disabilities. You may request any needed accommodation to participate in the application process.
Date:

MonthDayYear
Date
PERSONAL INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Are you at least 19 years of age?

YesNo
If not 19, are you at least 18 years of age?

YesNo
If not 18, are you at least 16 years of age?

YesNo
If under 18, can you submit a work permit?

YesNo
Are you legally authorized to work in the United States?*

YesNo
Activities Other Than Religious (Civic, Athletic, Fraternal, etc. Do not include organizations, the name or character of which indicate the race, religion, color, national origin, ancestry, age or handicap of its members:
EMPLOYMENT DESIRED
Position(s) applied for:*
Date you can begin*

MonthDayYear
Date
Salary desired*
What would you work?*

Full-TimePart-TimeTemporary
Specify day and hours if part time:*
Will you work Saturday?*
Will you work Sunday?*
Are you available to work overtime when necessary?*

YesNo
Are you able to perform the functions of the job for which you are applying (essential and/or marginal) with or without a reasonable accommodation.*

YesNo
Are you currently employed?*

YesNo
May we contact your present employer?

YesNo
Do you have any commitment to another employer which might affect your employment with us?
Current Salary $ per week
If you were employed under a name other than your present name, please indicate the former name:
Have you been convicted of any crime?*

YesNo
A conviction will not necessarily disqualify you from employment
If yes, explain:
Have you ever been discharged or requested to resign from a position?*

YesNo
If yes, give circumstances:
EDUCATION AND TRAINING
Type of school
Name of school
No. of years attended
Graduated?

YesNo
Major courses
MILITARY SERVICE
Branch
Dates

MonthDayYear
Date
Ending Rank
Present membership in Reserves or National Guard
Describe your duties:
OCCUPATIONAL HISTORY

(start with last employer first)
I. Company
Location
Phone Number

Area CodePhone Number
Job
Supervisor
Date started

MonthDayYear
Date
Date ended

MonthDayYear
Date
Salary
Reason for Leaving
II. Company
Location
Phone Number

Area CodePhone Number
Job
Supervisor
Date started

MonthDayYear
Date
Date ended

MonthDayYear
Date
Salary
Reason for Leaving
III. Company
Location
Phone Number

Area CodePhone Number
Job
Supervisor
Date started

MonthDayYear
Date
Date ended

MonthDayYear
Date
Salary
Reason for Leaving
IV. Company
Location
Phone Number

Area CodePhone Number
Job
Supervisor
Date started

MonthDayYear
Date
Date ended

MonthDayYear
Date
Salary
Reason for Leaving
WORK EXPERIENCE REFERENCES

Please list references other than relatives.
I. Name
Position
Company
Years Acquainted
Phone Number

Area CodePhone Number
II. Name
Position
Company
Years Acquainted
Phone Number

Area CodePhone Number
III. Name
Position
Company
Years Acquainted
Phone Number

Area CodePhone Number
State any additional information you feel may be helpful to us in considering your application:
PLEASE READ CAREFULLY:
I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification or omission of this information is grounds for refusal to hire or, if hired, dismissal.

I authorize any of the persons or organizations referred to in this application to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application and release all such parties from all liability for any damage that may result from furnishing such information to you. I authorize you to request and receive such information, and I will indemnify you against any liability that may result from making such investigation.

As a condition of my employment with the company, I agree that all information which I receive in the course of my employment relating in any manner to, among other things, the business activities, customers, production processes, financial affairs, programs, concepts or designs of My Life LLC are to be treated by me as trade secrets and kept in confidence, not to be disclosed to any unauthorized person either during or after my employment, or used by me in any manner adverse to the interests of My Life LLC. This policy is not intended to restrict an employee's right to discuss wages, hours and working conditions with coworkers, or in any way to limit an employee's exercise of rights under the National Labor Relations Act ("NLRA" Employees will not be disciplined or retaliated against for engaging in activities protected under the NLRA. Employees who have concerns or questions regarding their rights under the NLRA should contact the Corporate Human Resources Manager.
In consideration for my employment by your company, I agree to conform to the rules and regulations of the company and acknowledge that these rules and regulations may be changed, interpreted, suspended, withdrawn, or added to by your company at any time, at the company's sole option and without any prior notice to me.

I further acknowledge that my employment is at-will and may be terminated, and any offer of employment, if such is made, or my acceptance of an employment offer, if such is to occur, may be withdrawn, with or without cause, and with or without prior notice, at any time, at the option of the company or myself. I understand that no representative of the company other than the President, and then only in writing, signed by him and me, has any authority to enter into any agreement for employment for any specified period of time or to assure any other personnel action, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing. I understand that I cannot rely on any contrary oral or written statements. Employment with the Company is at-will. Employment at-will may be terminated with or without cause and with or without notice at any time by the employee or the Company. Nothing in this Application, the Company's Employee Handbook or in any document or statement and nothing implied from any course of conduct shall limit the Company's or employee's right to terminate employment at-will. No manager, supervisor, or employee of the Company has any authority to enter into an agreement for employment for any specified period of time or to make an agreement for employment other than at-will. Only the President of the Company has the authority to make any such agreement and then only in writing.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between My Life LLC and myself for either employment or for providing of any benefit.

I acknowledge that any offer of employment to me by My Life LLC is contingent upon my timely completing INS Form I-9 and producing the proper documents required by the Immigration Reform and Control Act of 1986. My failure to meet these requirements within the specified time will result in the termination of employment.

I understand that my employment and continued employment, if I am hired, is contingent upon the results of periodic background reports, and I expressly authorize My Life LLC to obtain such background reports in accordance with the Fair Credit Reporting Act.

If my services terminate after accepting employment, I understand that My Life LLC or any of its affiliates may supply, in confidence, my employment record to any prospective employer, with no liability to the Company or its staff.

I acknowledge that I have been advised that this application will remain active for no more than thirty (30) days from the date it was made.
Date:*

MonthDayYear
Date
Applicant Signature: *

Clear
Should be Empty:

MY LIFE LLC

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION AND TRAINING

MILITARY SERVICE

OCCUPATIONAL HISTORY

WORK EXPERIENCE REFERENCES

PLEASE READ CAREFULLY: