How long have you lived at this address?
If No, please state your age:
Position applying for:
Date available to start:
If yes, please identify:
If yes, When?
If yes, state the date and places where the charges occurred (Note: answering “yes” will not automatically disqualify you for employment):
In the event of an Emergency, Notify:
Name & Location
List any extracurricular activities, awards, scholarships, or clubs that you were involved in which might be related to the position for which you are applying:
Please give accurate and complete full/part time employment record. Start with your present or most recent employer first.
Note that all the employers listed above will be contacted unless the applicant indicates differently.
If yes, please indicate employer and reason:
List below the names of three persons, not related to you, whom you have known for at least one year.
Address & Phone
I hereby reaffirm that I have read the foregoing questions and that my answers to them are true and correct and that I have not misrepresented or withheld any information.
I understand that falsification of this information may be cause for immediate dismissal. I further acknowledge that my employment may be terminated, and the company or I
may withdraw any offer of employment without prior notice. I also understand that my employment is at will. This means I am free to terminate my employment at any time,
for any reason, and the company retains the same right. I understand that any offer of employment may be contingent upon a credit and criminal background investigation
and a pre-employment drug screen. I hereby authorize all references and former employers listed on my employment application to give the company any and all information
concerning my previous employment and any pertinent information they might have, personal or otherwise. I hereby release all parties, including agents, from any claims,
causes of action, or liability from damages that may or could result from furnishing such information to the company or as a result of information obtained through a
background investigation or drug screen.
Signature of Applicant: