EMPLOYMENT APPLICATION

NOTICE TO APPLICANTS

This employer complies with the American with Disabilities Act 1990. We will not use the information to discriminate against any individual with respect to their compensation, terms, conditions, or privileges of employment because of race, color religion, sex, age, national origin, marital status, sexual orientation, or disabilities.

Name *

First Name Middle Name Last Name

Social Security Number

Address

Street Address

Street Address Line 2

City State

Zip Code

Home Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Birthday *

Date

Have you ever been convicted of a misdemeanor or a felony? *

Yes No

If yes, please explain:

Desired Position *

Date Available *

Desired Hourly Pay

Minimum Hourly Pay

Sex *

Male Female

Veteran Status

Non Veteran Vietnam Era Veteran Other Veteran

Race

White Hispanic or Latin Black or African American American Indian / Alaskan Native Asian Native Hawaiian or Pacific Islander Two or more races

Are you a citizen of the Unites States? *

Yes No

If no, are you authorized to work in the United States?

Yes No

Please list any qualities or experience you would like us to know about:

Copy of your Driver's License

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Copy of your Social Security Card

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Name & Location of Employer (1)

Position

Contact & Title

Phone Number

Month/Year From Month/Year To .

Salary: Beginningblanks . Ending blank .

Reason for Leaving

Name & Location of Employer (2)

Position

Contact & Title

Phone Number

Month/Year From Month/Year To .

Salary: Beginningblanks . Ending blank .

Reason for Leaving

Name & Location of Employer (3)

Position

Contact & Title

Phone Number

Month/Year From Month/Year To .

Salary: Beginningblanks . Ending blank .

Reason for Leaving

Education (Completed with Degree or Diploma) *

High School College Technical School Other

Course of Study

Degree Earned & Year

I certify that the answers given herein are true and complete. I authorize investigation of statements contained herein as may be necessary. I understand that false statements, omissions, or misleading statements on this application shall be considered cause for dismissal. If my employment is terminated because of such omissions or misleading statements, I agree that my employers shall not be held liable in any respect.

Signature *

Clear

Today's Date *

Date

EMPLOYMENT APPLICATION

EMPLOYMENT HISTORY