APPLICATION FOR EMPLOYMENT

We appreciate your interest. We are an equal employment opportunity employer. Our policy is not to discriminate against any applicant or employee based on race, color, sex, religion, national origin, age (40 and over), disability, military status, genetic information, or any other basis protected by applicable federal, state, or local laws. We also prohibit harassment of applicants or employees based on any of these protected categories. It is also our policy to comply with all applicable federal, state, and local laws respecting consideration of unemployment status in making hiring decisions.

Note to Applicants: Smoking is prohibited in all indoor areas unless designated areas have been established by a particular location in accordance with applicable state and local law.

Please complete all requested information. Use ink and print.

Today's Date:

Date

Position Applying For

Name

First NameLast Name

Minimum Salary Desired

Date Available to start

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Telephone (Home) ( )

Telephone (Work) ( )

Are you at least 18 years old?

YesNo

Have you ever used any other name(s) which is (are) necessary for us to know in order for us to verify your employment or educational record?

YesNo

If yes, please provide the other name(s)

Are you available to work overtime as needed?

YesNo

Have you previously worked for or applied for a position with this Company, in any of our locations either as an employee or through an employment agency?

YesNo

Have you previously worked for or applied for a position with this Company, in any of our locations either as an employee or through an employment agency?

Have you ever been convicted of a felony or misdemeanor?

Are you related to or in a close personal relationship with anyone now employed at this Company? (An answer of “Yes” will not automatically disqualify you from the position for which you are applying)

YesNo

Have you ever been convicted of a felony or misdemeanor?

YesNo

Are you legally authorized to work in the United States?

YesNo

Will you now or in the future require sponsorship for employment visa statue (e.g., H-1B status)?

YesNo

Please specify your complete full-time and part-time employment history, including self-employment. You may include any verified work performed on a volunteer basis. Begin with your most recent employer. If you require additional space, please use the reverse side of this page and/or the following page.

Company Name

Telephone:

Address

Dates employed:

Name, Title, and Phone Number of Supervisor

Job Title, and Work Responsibilities

Reason for Leaving

Company Name

Telephone

Address

From To

Name, Title, and Phone Number of Supervisor

Reason for Leaving

Job Title, and Work Responsibilities

Company Name

Telephone

Address

From To

Name, Title, and Phone Number of Supervisor

Job Title, and Work Responsibilities

Reason for Leaving

(Employment record continued next page

Company Name

Telephone

Address

From To

Name, Title, and Phone Number of Supervisor

Reason for Leaving

Job Title, and Work Responsibilities

All employers, including your current employer, may be contacted to verify the information you provide. May we contact your current employer prior to any offer of employment?

YesNo

Individuals not related to you. Business references preferred.

	Name	Occupation	Phone	Address	Years Known and Capacity
Reference #1
Reference #2
Reference #3

Please include name, street, city, state, and zip code for each school.

School

	Name and Location of School	Number of Years Completed	Degree	Type of Course/Major
Graduate
College
High School
Business/Trade/Technical

Please summarize your jobrelated skills and qualifications

If applying for a position that will include driving: If hired, you may be required to provide evidence of insurance or insurability.

YesNo

Emergency Contact Person

First NameLast Name

Phone Number

Please enter a valid phone number.

THIS APPLICATION IS NOT COMPLETE UNTIL IT IS FULLY COMPLETED, SIGNED AND ALL STATEMENTS BELOW HAVE BEEN READ AND INITIALED.

I certify that all the information furnished on this application and during the application process is true, complete, and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts called for may result in refusal to hire or if hired, may result in my dismissal at any time regardless of when the false answer or omissions are discovered.

I recognize that this employment application is not an offer of employment. I agree that if I am hired by the Company, I will be an at-will employee, meaning that either the Company or I may end the employment relationship at any time with or without cause or notice. I understand that only authorized representatives with explicit authority to enter into agreements, and no manager, supervisor, or other non-authorized representative of the Company, has authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the at-will employment relationship, and with respect to any agreement entered into by the explicitly authorized representative, and by me or my authorized representative. You may contact human resources to inquire as to who the explicitly authorized representative is.

Initial

I further understand and agree that, except for my at-will employment status, if hired, my wages, hours, working conditions, job assignment(s), and compensation rate(s) will be subject to change by the Company.

Initial

I understand that if I am offered employment, I may be required to sign a non-solicitation and non-disclosure agreement, as a condition of employment.

Initial

I understand that the Company may share the information contained in this application with other Company employees for employment and administrative purposes and hereby consent to such transfer.

Initial

I hereby authorize, to the extent allowed by applicable federal state and local laws, the Company to conduct its own investigation of my references, employment history and education and, further, authorize the references and prior employers I have listed to disclose to the Company information related to my employment history and qualifications for the position for which I am applying, without giving me prior notice of such disclosure.

Initial

I understand and expressly agree that if employed by the Company, storage areas proved for me locker, desk, etc are open to investigation by the Company without prior notice to me.

Initial

I agree to undergo a pre-employment physical examination consistent with federal and state law.

Initial

I agree to submit to legally permissible drug testing upon an offer of employment from the Company and prior to starting work. I agree that any offer of employment is contingent upon my receiving a negative test result.

Initial

Delaware, Massachusetts, New York, Oregon, Puerto Rico, and California Applicants: I understand that the Company may not ask or require applicants to disclose past salary, wages, or other compensation.

Initial

Massachusetts Applicants: I understand that it is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continue employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Maryland Applicants: I UNDERSTAND THAT UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT OR CONTINUED EMPLOYMENT, THAT ANY INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

Initial

My signature below certifies that I agree to be bound by the terms and conditions stated in this application, which contains all the understandings between the Company and me concerning the topics addressed herein and supersedes any prior inconsistent understandings between the Company and me on such issues.

APPLICANT’S SIGNATURE DATE

Date

This application will only be considered for 30 days. If you have not been hired within 30 days of submitting this application and you wish to continue to be considered for employment, you must complete another application.

APPLICATION FOR EMPLOYMENT

GENERAL INFORMATION

WORK EXPERIENCE

PROFESSIONAL REFERENCES

EDUCATION & TRAINING

JOB-RELATED SKILLS AND QUALIFICATIONS

ADDITIONAL EMPLOYMENT INQUIRIES

APPLICANT’S STATEMENT & ACKNOWLEDGEMENT