Applicant Information fields with * are required
 Position:*  Are you over 18? Yes   No
 First Name:* MI:  Last Name:*
     Email Address:*
 Address:*  City:*
 State:*  Zip Code:*
 Day Phone:* (digits only)  Evening Phone: (digits only)
 Date available for employment  Desired salary:
 Date:    
 Type of Employment Desired: Full-time    Part-time
       
 Are you legally eligible for employment in the United States? Yes    No
 Have you ever pled guilty or been convicted of a crime? Yes    No   If Yes, please explain.
May we contact you at work? Yes    No
       
 Education
  Name and Location Course of Study Years
Completed		 Cert, Diploma
or Degree
 High School or Equivalent
 Postsecondary Vocation School
 College or University
 Other Education/Special Training/
 Military Schools
       
       
 Employment History  (Most Recent Jobs First)
 Company:  Dates:  To
 Address:  
 Supervisor:  Phone:
       
 May we contact your
 supervisor/employer?		 Yes    No  Reason for leaving
       
Beginning hourly rate/salary Final hourly rate/salary
       
 Job title and duties:
 
       
       
 Company:  Dates:  To
 Address:  
 Supervisor:  Phone:
       
 May we contact your
 supervisor/employer?		 Yes    No  Reason for leaving
       
Beginning hourly rate/salary Final hourly rate/salary
       
 Job title and duties:
 
       
       
 Company:  Dates:  To
 Address:  
 Supervisor:  Phone:
       
 May we contact your
 supervisor/employer?		 Yes    No  Reason for leaving
       
Beginning hourly rate/salary Final hourly rate/salary
       
 Job title and duties:
 
       
       
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 you are applying for. 
 
       
       
 References:  Please list three professional references.
 Name:  Occupation:
 Address:  Phone:
Number of years know
 Name:  Occupation:
 Address:  Phone:
Number of years know
 Name:  Occupation:
 Address:  Phone:
Number of years know
I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to cancel further consideration of this application, and/or immediately discharge me from my employment, if already working, whenever it is discovered. I authorize, without reservation, the employer and its representatives to contact and obtain information from all references (personal and professional), employers, licensing authorities and educational institutions and otherwise verify that accuracy of all information provided by me in this application, resume, or job interview. I hereby waive all rights and claims I may have regarding the employer, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question in this application is used for the purpose of limiting or excusing any applicant from consideration for employment on the basis prohibited by applicable local, state or federal law. I understand that this application remains current for one year. At the conclusion of that time, if I wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that the company is an "at will" employer, and 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 also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.



DO NOT SUBMIT THIS FORM UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.  Yes