employment   Last Name First Name Middle Initial Street Address City State Zip Code Social Security # E-mail Address Date of Birth - - Home Phone Other Phone Employer Position(s) applied for:   If you are under 18, and it is required, can you furnish a work permit? If no, please explain Yes No   Have you ever been employed here before? Yes No   Are you legally eligible to work in this country? Yes No   Date Available for work Type of employment desired   / / Full-Time Part-Time Temporary Seasonal Educational / Co-Op Have you been convicted on a crime in the last (7) years? If yes, please explain Yes No   Drivers license number if driving is an essential job function State       Work Experience List present and former employers beginning with the most recent From Employer Phone To Address     Job Title Summarize the nature of work performed and job responsibilities   Immediate Supervisor and title Hourly Rate/Salary     Reason for leaving Per Hour Week Month Year           From Employer Phone To Address     Job Title Summarize the nature of work performed and job responsibilities   Immediate Supervisor and title Hourly Rate/Salary     Reason for leaving Per Hour Week Month Year           From Employer Phone To Address     Job Title Summarize the nature of work performed and job responsibilities   Immediate Supervisor and title Hourly Rate/Salary     Reason for leaving Per Hour Week Month Year           From Employer Phone To Address     Job Title Summarize the nature of work performed and job responsibilities   Immediate Supervisor and title Hourly Rate/Salary     Reason for leaving Per Hour Week Month Year           Skills and Qualifications Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying           Record of Education (if job related)       Name and location Yrs. Comp. Did you graduate? Course of study High School College Other       Personal References (not former employers of relatives)   Name Phone Years Known       To be completed by all applicants - Please read carefully before signing I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION AND IN ANY RESUME PROVIDED BY ME OR ANY PARTY REPRESENTING MY INTERESTS IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS, MISREPRESENTATIONS OR OMISSIONS MADE BY ME ON THIS APPLICATION OR ANY SUPPLEMENT THERETO, WILL BE SUFFICIENT GROUNDS FOR REJECTION OF THIS APPLICATION OR DISCHARGE AFTER EMPLOYMENT. I GIVE THE EMPLOYER THE RIGHT TO OBTAIN PERTINENT INFORMATION CONCERNING ME FROM FORMER EMPLOYERS AND OTHERS, AND I RELEASE ALL THOSE PROVIDING OR REQUESTING SUCH INFORMATION FROM ANY LIABILITY THAT MAY ARISE BY TRUTHFUL DISCLOSURES OR SUCH INVESTIGATIONS. IF I AM HIRED, I UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, AND THE EMPLOYER RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, EXCEPT AS MAY BE REQUIRED BY LAW. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF THE EMPLOYER, OTHER THAN AN AUTHORIZED OFFICER, HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER. I UNDERSTAND IT IS THE COMPANY'S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIDUAL WITH A DISABILITY BECAUSE OF THAT PERSON'S NEED FOR A REASONABLE ACCOMMODATION AS REQUIRED BY THE ADA. I ALSO UNDERSTAND THAT IF I'M HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION.     Your digital signature acknowledges you have read and agreed to the material above. ( Check here to digitally sign )

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