APPLICATION FOR EMPLOYEMENT

We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, sexual orientation, marital status, genetic information, or any other status protected by law or regulation. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors

Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for signature on back of application. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job related information.

Job applied for

Are you seeking:

Full-timePart-timeTemporary

Today’s date

Date

When could you start work?

Are you 18 years of age or older?

YesNo

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.

If hired, you will be required to furnish proof of your eligibility to work in the U.S. Are you over the age of 18? (If you are hired, you may be required to submit proof of age.)

YesNo

Have you ever applied here before?

YesNo

If yes, when?

Have you ever been employed at NMI?

YesNo

If yes, when?

If employed, do you expect to be engaged in any additional business or employment outside of our job?

YesNo

If yes, give details

Please list education history

	List name of School and address	# of years completed	Diploma/ Degree/ Certificate	Subjects Studied
High School or GED
College or University
Vocational or Technical

What skills or additional training do you have that are related to the job for which you are applying?

What machines or equipment can you operate that are related to the job for which you are applying?

For driving jobs only: Do you have a valid driver’s license?

YesNo

Driver’s License Number

Class of license

State licensed in

Have you had your driver’s license suspended or revoked in the last 3 years?

NoYes

If yes, please give details

List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability, genetic information or other protected status.

Previous employment

	History
Empolyer Name
Phone number & Location
Start to finish date
Supervisor name & Phone number
Reason for leaving
Title at company

Previous employment

	History
Empolyer Name
Phone number & Location
Start to finish date
Supervisor name & Phone number
Reason for leaving
Title at company

Previous employment

	History
Empolyer Name
Phone number & Location
Start to finish date
Supervisor name & Phone number
Reason for leaving
Title at company

Previous employment

	History
Empolyer Name
Phone number & Location
Start to finish date
Supervisor name & Phone number
Reason for leaving
Title at company

Have you worked or attended school under any other names?

YesNo

If yes, give names

Are you presently employed?

NoYes

If yes, whom do you suggest we contact?

Have you ever been fired from a job or asked to resign?

YesNo

If yes, please explain

Give three references, not relative or former employers.

	Name	Address	Phone Number
#1
#2
#3

Affidavit, Consent, and Release

Please read each statement carefully before signing

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/ post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

I have read, understand, and by my signature consent to these statements.

Signature:

Date

This application for employment will remain active for a limited time. Ask the organization’s representative for details.

APPLICATION FOR EMPLOYEMENT

An Equal Opportunity Employer

Education

Special Skills

Work History

241 Racquette Drive, Fort Collins, Colorado 80524 Ph: (970) 556-3130