TRrOR EMPLOYMENT

ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE; COLOR;

RELIGION; GENDER (INCLUDING PREGNANCY); NATIONAL ORIGIN; AGE (40 OR OLDER);
GENETIC INFORMATION; MARITAL, PARENTAL, OR VETERAN STATUS; SEXUAL ORIENTATION;
POLITICAL AFFILIATION; THE PRESENCE OF A NON-JOB RELATED HANDICAP; OR ANY OTHER
LEGALLY PROTECTED STATUS.
Position Sought: ________________________________

How did you learn about the position? ________________________________

Name________________________________ Date________________

Address________________________________ City___________________ State________ Zip______

_

Home Phone ____________________Office Phone___________________Other

Phone_________________

Email Address: ______________________________

Social Security Number:_________________________.

On what date would you be available for work? ____________________ Desired Wage/Salary
$_____________
Are you a U.S. citizen, or are you otherwise authorized to work in the U.S. without any restriction? [ ]
Yes [ ] No
Have you ever been convicted of a felony? [ ] Yes [ ] No If yes, please describe
circumstances: __________
________________________________

Have you ever been involuntarily terminated or asked to resign from any position of employment? [ ]
Yes [ ] No
If yes, please describe circumstances: ________________________________
________________________________
If selected for employment, are you willing to submit to a pre-employment drug screening test? [ ]
Yes [ ] No

EDUCATION

School Name Location Years Degree Major

Attended Received
Other training, certifications, or licenses held: ________________________________
________________________________

List other information pertinent to the employment you are

seeking: ________________________________
________________________________

EMPLOYMENT

(Most Recent First.)

1. Employer________________________________ Job Title_________________________

Dates Employed______________ Prior Position Held within Company (if any):

________________________

Address________________________________ City___________________ State________ Zip______

___

Phone____________________ Job
Title_______________________ Supervisor_______________________

Starting Salary________________________________ Ending

Salary______________________________

Duties Performed ________________________________

Reason for Leaving ________________________________

2. Employer________________________________ Job Title_________________________

Dates Employed______________ Prior Position Held within Company (if any):

________________________

Address________________________________ City___________________ State________ Zip______

___

Phone____________________ Job
Title_______________________ Supervisor_______________________

Starting Salary________________________________ Ending

Salary_______________________________

Duties Performed ________________________________

Reason for Leaving ________________________________

3. Employer________________________________ Job Title_________________________

Dates Employed______________ Prior Position Held within Company (if any):

________________________

Address________________________________ City___________________ State________ Zip_______

__

Phone____________________ Job
Title_______________________ Supervisor_______________________

Starting Salary________________________________ Ending

Salary_______________________________

Duties Performed ________________________________

Reason for Leaving ________________________________

4. Employer________________________________ Job Title_________________________

Dates Employed______________ Prior Position Held within Company (if any):

________________________

Address________________________________ City___________________ State________ Zip______

___

Phone____________________ Job
Title_______________________ Supervisor_______________________

Starting Salary________________________________ Ending

Salary_______________________________

Duties Performed ________________________________

Reason for Leaving ________________________________

ACKNOWLEDGMENT AND AUTHORIZATION

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be
necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.
Any applicant wishing to be considered for employment beyond this time period should inquire as to
whether or not applications are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment
relationship with this organization is of an "at will" nature, which means that the Employee may resign at
any time and the Employer may discharge Employee at any time with or without cause. It is further
understood that this "at will" employment relationship may not be changed by any written document or by
conduct unless such change is specifically acknowledged in writing by an authorized executive of this
organization.

In the event of employment, I understand that false or misleading information given in my application or
interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and
regulations of the Employer.

________________________________ ___________________

Signature of Applicant Date