Are you capable of satisfactorily performing the essential job duties required of the position for which you are applying?
Yes No -

How did you hear of this position?

Personal Information

Phone Numbers:
Daytime Phone:

Evening Phone:

Best Time to Call:


How would you like us to contact you:
 Day Phone  Evening Phone E-Mail

Address Information

Current Street Address:

City:

State:

Zip:

How Long Current Address:

Previous Address:
(if less than 5 years)

City:

State:

Zip:

How Long at Previous Address

Driver License Information 

Do you have a reliable means of transportation to travel to and from work which will allow you to consistently arrive at work on time? 
Yes No -
If a driver's license is required for the position for which you are applying, do you have a valid driver's license? 
Yes No -  
License Number: 

State:

Expiration Date:

Have you been cited for a traffic violation of any kind within the last FIVE years?
Yes No -
If yes, please give date and details:

NOTE: An affirmative answer to the following question will not automatically disqualify you from which you are applying.  Factors such as age of the conviction, time of events, seriousness and nature of the violation, and rehabilitation are taken into account.

Have you ever pled guilty or "no contest" to a crime or been convicted of a crime:
Yes No -
If yes, please give date and details of each:

Work History

Have you ever worked for this Company before? 
Yes No -
If yes, please give dates and position: 

Do you have any friends or relatives working here? 
Yes No - If yes, Name:

Please list the names of your previous employers in chronological order with present of last employer listed first. Be sure to account for all periods of time including military service and any period of unemployment, if self-employed, give firm name and supply business references.

How many days of work have you missed in the last THREE years due to reasons other than paid holidays and vacation?

Year: Number of Days Missed:

Year: Number of Days Missed:

Year: Number of Days Missed:

Have you ever been terminated or asked to resign from any job? 
Yes No -
If yes, please explain circumstances:

Please explain fully any gaps in your employment history:

May we contact your current employer?
Yes No -
If no, please explain:

Education

Disclosure

WE ARE AN EQUAL OPPORTUNITY EMPLOYER
APPLICANT'S STATEMENT

I understand that this application will be given every consideration, but it is not a promise of employment.

I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of my wages.  I further understand that I have the right to terminate my employment at any time with or without notice, and the Company has the same right.  No one other than the President of the Company has authority to modify this relationship or to make any agreement to the contrary.  Any such modification or agreement must be in writing.

I understand that the Company reserves the right to require me to submit to a test for the presence of drugs in my system prior to employment and at any time during my employment, to the extent permitted by law.  I also understand that any offer of employment may be contingent upon the passing of a physical examination, and a test for the presence of alcohol in my system, performed by a doctor selected by the Company,  Further, I understand that at any time after I am hired, the Company may require me to submit to a physical examination, and an alcohol test, to the extent permitted by law.  I consent to the disclosure of the results of the physical examinations and related tests to the Company.  I also understand that I may be required to take other tests, such as personality and honesty test, prior to employment and during my employment.

I understand that the Company may investigate my driving record and my criminal record and that an investigative consumer report may be prepared whereby information is obtained through personal interviews with my neighbors, friends and others with whom I am acquainted.  This inquiry includes information as to my character, general reputation, personal characteristics and mode of living.  I understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.  I further understand that the Company my contact my previous employers and I authorize those employers to disclose to the Company all records pertinent to my employment with them.  In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights or claims I have or may have against my former employers, their agents, employees, and representatives, as well as other individuals who release information to the Company, and release them from any and all liability, claims, or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me.

I hereby state that all of the information that I provide on this application and in interview is true and accurate.  I understand that if I am employed and any such information is later found to be false in any respect, I may be dismissed.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF THIRTY (30) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND ACCURATE.

DATE: SIGNATURE OF APPLICANT:

(You will be asked to sign this, if needed.)