We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or

veteran status, or any other legally protected status.

Position(s) Applied For

Date of Application

How Did You Learn About Us?

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Employment Agency

Relative

Friend

Inquiry

Other

Last Name

First Name

Middle Name

Address

City

Zip Code

State

Telephone Number(s)

Can you provide required proof of your eligibility to work?

Yes

No

Hvae you ever filed an application with us before? If Yes, give date:

Yes

No

Have you ever been employed with us before? If Yes, give date:

Yes

No

Do any of your friends or relatives, other than spouse, work here?

Yes

No

Are you currently employed?

Yes

No

May we contact your present employer?

Yes

No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Yes

No

Are you currently on "lay-off" status and subject to recall?

Yes

No

Can you travel if a job requires it?

Yes

No

Date available to work

What is your desired salary range?

Are you available to work:

Full-Time (please indicate 1 2 3 shift)

Part-Time Mornings

Part-Time Afternoons

Part-Time Evenings

Temporary (please indicate dates available)

If daily overtime is required that goes beyond assigned shift, is it possible for you to work?

Yes

No

If weekend or additional days are required, can you work the additional hours?

Yes

No

Have you ever been convicted of a crime in the last 5 years? (Do not include misdemeanors or traffic violations)

If yes, please explain:

Yes

No

Have you ever been disciplined, discharged or asked to resign from a job in connection with loss of money, merchandise or equipment?

If yes, please explain:

Yes

No

Have you ever been disciplined or discharged for absenteeism or tardiness?

If yes, please explain:

Yes

No

Have you ever been disciplined or discharged for any other reason?

If yes, please explain:

Yes

No

Please submit a resume or curriculum vitae.

Driver's License Number:

State Where Issued:

(Please provide copy)

Valid C. D. L. Class

A

B

C

List Endorsements:

Certification of Power Equipment:

Yes

No

Do you hold a valid D.O.T. Physical Card:

(Please provide copy)

Yes

No

I certify that answers herein are true and complete.

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 should 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 applicants 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 "at will" nature, which means that the Employee may resign at any time and the Employer may discharge the 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 a 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.