Employment Application "*" indicates required fields Step 1 of 5 20% Equal access to programs, services and employment is available to all persons. Those applicants requiring a reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. We are an equal opportunity employer. Date of Application Submission* Month Day Year Position applied for:* Personal Information Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Enter Email Confirm Email Home PhoneCellular #Would you accept full-time work?* Yes No Would you accept part-time work?* Yes No What shift would you prefer?* 1 2 3 Any Expected pay (*Required)* If necessary, best time to call you is?* On what day would you be available for work?* How were you referred to our Company?* Have you submitted an application here before?* Yes No If yes, please give date(s) and position(s): Other Information Have you ever been employed here before?* Yes No If yes, please give date(s): Is this application a request for reemployment following an extended military leave of absence from our Company?*If yes, additional information may be requested. Yes No If you are under 18 years old, can you provide a work permit if required?*If yes, additional information may be requested. Yes No Are you legally eligible for employment in the United States? (If yes, proof is required if hired.)* Yes No Are you able to perform the "essential functions" of the job for which you are applying (with or without accommodation)?*NOTE: This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage, to the extent permitted by law. Yes No Need more information about the job's "essential functions" to respond Will you travel if required?* Yes No Will you work overtime if required?* Yes No If they have been explained to you, are you able to meet the attendance requirements of the postion?* Yes No N/A Have you ever been bonded?* Yes No Please provide your driver's license number, if driving is required for the job.*License Number * State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our Company? Yes No If yes, please explain: Have you ever plead "guilty" or "no contest" to, or been convicted of, a crime?*NOTE: Answering "yes" to the above question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. Yes No If yes, please provide date(s) and details: Employment History Position 1May we contact the employer? Yes No Employer Contact Name Email Address PhoneSupervisor Date Employed From: Month Day Year Your Job Title at this Employer Date Employed To: Month Day Year Starting hourly rate/Salary Ending hourly rate/Salary Work PerformedReason for Leaving What did you like most about your position?What did you like least about your position?Position 2May we contact the employer? Yes No Employer Contact Name Email Address Supervisor PhoneDate Employed From: Month Day Year Your Job Title at this Employer Date Employed To: Month Day Year Starting hourly rate/Salary Ending hourly rate/Salary Work PerformedReason for Leaving What did you like most about your position?What did you like least about your position?Position 3May we contact the employer? Yes No Employer Contact Name Email Address PhoneSupervisor Date Employed From: Month Day Year Your Job Title at this Employer Date Employed To: Month Day Year Starting hourly rate/Salary Ending hourly rate/Salary Work PerformedReason for Leaving What did you like most about your position? Explain any gaps in your employment, other than those due to personal illness,injury or disability.Have you ever been fired or asked to resign from a job?* Yes No If yes, please explain:Education Background PrimaryHigh School Location: Course of Study Did you graduate High School? Yes No Degree or Diploma SecondaryCollege or University Location: Course of Study Did you graduate? Yes No Degree or Diploma Post SecondaryGraduate School: Location: Course of Study Did you graduate? Yes No Degree or Diploma Additional EducationVocational Training/Other: Location: Course of Study Certificate/License received? Yes No Degree or Diploma Continuing EducationContinuing Education:Special Training or Skills Languages, machine operation, etc., that would be of benefit in the job for which you are applying.Languages, machine operation, etc., that would be of benefit in the job for which you are applying.Social Security Number SS# The Company will make reasonable efforts to safeguard the privacy of this information and will use it only for employment purposes References List names and telephone numbers of three business/work references who are NOT related to you and are not previous supervisors. If not applicable, list three school or personal references who are NOT related to you.Reference 1Name* Title* Relationship* Years Known* Telephone* Email* Reference 2Name* Title* Relationship* Years Known* Telephone* Email* Reference 3Name* Title* Relationship* Years Known* Telephone* Email* Applicant StatementApplicant Statement and Digital Signature I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time. If hired, I agree to conform to the Company’s rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either express or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or the Company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company. I understand that no Company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, résumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. I also understand that, if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States as required by federal immigration laws. This Company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local law. No question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law. Applicant Digital Signature* First Last Please attach resume, cover letter, license ( if applicable) Drop files here or Select files Accepted file types: pdf, doc, docx, txt, Max. file size: 25 MB.
