revised EMPLOYMENT APPLICATION

Employment Application Please fill out completely. Type in your information or handprint using a black or blue pen.

NAME: (Last, First, Middle)

Address

Street address

Street Address Line 2

City State Zip

Telephone Numbers

Email address

Drivers license number,state, and expiration if job involves any driving

Position applied for

How did you hear about this position

Date available for work

Date

Desired hours full time part time etc

High School, Undergraduate College and Graduate. List all

List any seminars classes or other education not listed above which may help qualify you for this position.

Employment History List below all present and past employers over the past ten years, starting with your most recent employer. Account for all periods of unemployment. You must complete this section even if attaching a resume.

Previous Employer No. 1

Address

City State Zip

Start Date

Date

End Date

Date

Essential Job functions of final position

Starting Pay

Ending Pay

Supervisors

Supervisor(s) Phone Number

Email address of supervisor

example@example.com

Reasons for leaving or wanting to leave if currently employed

What value did you add to this company or its customers

Previous Employer No. 2

Address

Start Date

Date

End Date

Date

Essential Job functions of final position

Starting Pay

Ending Pay

Fax number

Supervisors

Supervisor(s) Phone Number

Job positions

Reasons for leaving

Email address of supervisor

example@example.com

What value did you add to this company or its customers

Previous Employer No. 3

Address

City State Zip

Essential Job functions of final position

Start Date

Date

End Date

Date

Fax number

Starting Pay

Ending Pay

Job positions

Supervisors

Supervisor(s) Phone Number

Reasons for leaving

Email address of supervisor

example@example.com

What value did you add to this company or its customers

Previous Employer No. 4

Address

City State Zip

Start Date

Date

End Date

Date

Essential Job functions of final position

Starting Pay

Ending Pay

Fax number

Supervisors

Supervisor(s) Phone Number

Job positions

Reasons for leaving

Email address of supervisor

example@example.com

What value did you add to this company or its customers

Previous Employer No. 5

Address

City State Zip

Essential Job functions of final position

Start Date

Date

End Date

Date

Fax number

Starting Pay

Ending Pay

Job positions

Supervisor

Supervisor's Phone Number

Reasons for leaving

Email address of supervisor

example@example.com

What value did you add to this company or its customers

List any professional trade business or civic activities and offices held You may exclude membership that would reveal gender race religion national origin ancestry age disability or any other protected status

Identify formal job training that relates to this position

Identify what skills or certifications you possess related to this position

If hired what value would you bring to our company

Describe what you believe are the most unique features of your work history

Have you ever been employed with this company before? Indicate YES or NO and if yes when?

Do you have any friends or relatives emploed by this company. Answer YES or NO. If Yes please provide their names and relationship to you

Are you currently employed? Answer YES or NO

May we contact your employer? Answer YES or NO

Are you currently on "lay off" status and subject to recall? Answer YES or NO

INSTRUCTIONS FOR ANSWERING APPLICATION QUESTION ABOUT BEING CONVICTED OF A CRIME OR OTHER STATE-SPECIFIC REQUIREMENTSPlease respond to the following questions in the most complete and accurate manner possible. Do not identify convictions for convictions for which the criminal record has been expunged or sealed by the court or, misdemeanor convictions for which any probation has been completed and the case dismissed by the court. Furthermore, please note that no applicant will be denied employment solely on the grounds that they have been charged, committed, or convicted of (or pleaded guilty or no contest in) a criminal offense, or solely on an affirmative answer. The nature, date, surrounding circumstances and relevance of the offense to the position(s) applied for will be considered. A criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job in question. If you are applying for a position with our company in the following states, please read the instructions which follow below before responding.Have you ever, under your name or another name, been convicted off (or pleaded no contest to) a felony or misdemeanor? YesNo Have you ever, under your name or another name, been convicted of a crime, which resulted in you being in prison and/or jail and released from prison and/or jail or paroled? Yes or No If yes to either question above, please fully explain when, where and of what you were convicted and the result of the case(s). Are you currently under arrest, or released on bond on your own recognizance, pending trial for a criminal offense? Yes or No

If yes state the nature of the crime charged and when and where the trial is pending

List below three persons not related to you who have knowledge of your work performance within the last 5 years

Name

Telephone Number

Name

Telephone Number

Name

Telephone Number

Please read each statement closely and initial each acknowledging your understanding

Equal Employment Opportunity Statement This company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. The Company desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, age or any other status protected by Federal, State or local laws. The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the company.

This company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit We are committed to complying with all Federal State and local laws providing for equal employment opportunities as well as all laws related to terms and conditions of employment The Company desires to maintain a work environment that is free of sexual harassment and discrimination due to race religion color national origin physical or mental disability age or any other status protected by Federal State or local laws The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the company

This Company will not tolerate any form of unlawful discrimination including sexual harassment Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline up to and including termination Prohibited sexual harassment is defined as follows Unwelcome sexual advances requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when 1 submission to such conduct is made whether explicitly or implicitly a term or condition of an individuals employment 2 Submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals or 3 Such conduct has the purpose or effect of unreasonably interfering with an individuals work performance or creating an intimidating hostile or offensive work environment

Discrimination and Sexual Harassment Policy Statement This Company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual's employment; (2) Submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) Such conduct has the purpose or effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile or offensive work environment.

If you are offered a position with the Company you may be given a drugalcohol test as a condition of employment Your refusal to timely submit to a drugalcohol test or your failure to pass such a test means you will not be employed by this company Neither the collector of specimens nor the medical professional who reviews the test results will be a company employee The test results will be kept confidential The individual undergoing testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen Negative test results are required as a condition of employment

Disclosure to Applicants Concerning Drug/Alcohol Testing If you are offered a position with the Company, you may be given a drug/alcohol test as a condition of employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this company. Neither the collector of specimens nor the medical professional who reviews the test results will be a company employee. The test results will be kept confidential. The individual undergoing testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen. Negative test results are required as a condition of employment.

I herewith affirm that the employer has an offer of employment to me conditioned on the satisfactory completion of this questionnaire and if necessary at the sole discretion of the employer a medical examination

Medical History Questionnaire I herewith affirm that the employer has an offer of employment to me, conditioned on the satisfactory completion of this questionnaire, and, if necessary, at the sole discretion of the employer, a medical examination.

The purpose of this inquiry is to determine whether I currently have the physical or mental qualifications necessary to perform the job that has been offered; whether and what accommodations may be necessary; and whether I can perform the job without posing a direct threat to the health or safety of myself or others; and for the purposes and reasons as stated in the attached questionnaire. This information will be kept confidential in a separate medical file, apart from my personnel file. I herewith affirm that the questions found in the attached medical questionnaire have not be asked of me by anyone with the employer until after I have signed a separate document and have been offered a job.

Name

Signature

Witness

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge I further certify that I have personally completed this application I understand that any omission or misstatement of material fact on this application or any other document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed regardless of the time elapsed before discovery

At-Will Employment I understand and agree that if I am employed, my employment will be "at-will", which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the Company will respect my right to terminate my employment at any time, with or without cause and with or without notice. I further understand that any prior representation, whether expressed or implied to the contrary is hereby superceded and that no promise or representation contrary to the foregoing is binding on the Company unless made in writing and signed by the Company's president.

Testing Authorization If offered a position with the Company, I hereby agree to any legally permitted physical, psychological, skill, drug or medical test required by the Company as a condition of employment.

Investigation Authorization I authorize investigation into all statements and references contained in this application. Said investigation may include interviews with past employers, workers and friends. Said investigation may include credit, driving, criminal background, references and other background checks. As a condition of applying for this job, I authorize reasonable post-hire investigations into my credit, driving and criminal background.

Company Obligation I understand and agree that the Companys acceptance of this job application does not mean that a position for which I am qualified is open unless specifically posted or that the company has agreed to hire me I understand that the Company is under no obligation to hire me as the result of accepting this completed application

MY ANSWERS HAVE BEEN TRUE AND ACCURATE PURSUANT TO THE PENALTY OF PERJURY UNDER THE LAWS OF THIS STATE. I HAVE READ AND UNDERSTAND THE ABOVE POLICY STATEMENTS AND AGREE TO BE BOUND BY THEM IF EMPLOYED BY THE COMPANY.

Signature

Date

For Personnel Department Use Only

1 Application reviewed on

by

2 Denial letter sent

3 Interview letter sent

4 Interview scheduled for

ADDITIONAL NOTES

Essential job functions of final position

Today's Date:

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