Application (To print, select the PRINT option on the previous page!) Social Security # _______-______-_______ Date: _______________ Name: __________________________________________________________________________ (Last / First / Middle) Address: ________________________________________________________________________ (No. Street / City / State / Zip) Telephone: (_____) ________-___________ Email Address: ________________________ Are you 18 years of age or older? __Yes __ No If hired, can you provide written evidence that you are authorized to work in the U.S.? __ Yes __No EDUCATION
Type	Name/Location		Course of Study			# Years Completed		Degree/ Diploma
Elementary & Jr. High	_______________________________		____________			__________		________
HighSchool	_______________________________		____________			__________		________
College	_______________________________		____________			__________		________
Technical or Other	_______________________________		___________			__________		________
EMPLOYMENT RECORD
Company Name and address		Kind of Work		Date: Started/Left	Rate of Pay		Reason for Leaving
1.______________________________ | _____________ | __________ | ______ | ____________
2.______________________________ | _____________ | __________ | ______ | ____________
3.______________________________ | _____________ | __________ | ______ | ____________
4.______________________________ | _____________ | __________ | ______ | ____________
U.S. MILITARY SERVICE Branch of Service _________________________________________________________________ From _______________________ to _________________________ Rank and Type of Service _________________________________________________ Training/Experience Received ________________________________________________ REFERENCES (Do Not Include Relatives) Name/ Occupation/ Years/ Known Address 1. _________________________________________________________________________ 2. _________________________________________________________________________ 3. ___________________________________________________________________________ EMPLOYMENT Type of Work Desired ______________________________________ Salary Desired ___________ How Were You Referred To Our Organization? __________________________________________ Do You Have Any Relatives Who Are Employed By This Organization? __Yes __No Please Specify : ___________________________________________________________________ Is there any information we would need about your name, or use of another name, for us to be able to check your work record? __Yes __ No Please Specify : ___________________________________________________________________ Please list any additional information that relates to your ability to perform the job for which you have applied such as licenses, professional memberships, hobbies, etc. _________________________________________________________________________________ _________________________________________________________________________________ APPLICANT'S STATEMENT I understand that the employer follows an “employment at will” policy, in that I or the employer may terminate my employment at any time, or for any reason consistent with applicable state or federal law; this “employment at will” policy cannot be changed verbally or in writing, unless the change is specifically authorized in writing by the chief operating officer of this organization. I understand that this application is not a contract of employment. I understand that federal law prohibits the employment of unauthorized aliens; all persons hired must submit satisfactory proof of employment authorization and identity; failure to submit such proof will result in denial of employment. I understand this application will be active for a period of one year; after that time, if I wish to be considered for employment, I must submit a new application. I understand that the employer will thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorize all individuals, schools, and firms named   therein, except my current employer if so noted, to provide any information requested about me, and I release them from all liability for damage in providing this information. I certify that all the statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment. Your Signature: ______________________________________________ Date: _______________