Employment Application

We do not discriminate on the basis of race, color, religion, national original, sex, age, or disability. It is our
intention that all qualified applicants are given equal opportunity and that selection decisions be based on
job-related factors.

Personal Information
Name: Last:       First:       MI.:      

Address:       City:       State:       Zip:      

Home Phone:       Cell Phone:       Email:      

Social Security Number:       Are you 18 years or older?      

If hired, can you furnish proof you are eligible to work in the U.S? Yes No

General Questions
Are you known by another name? Yes No If yes, specify?      

Have you ever applied here before? Yes No If yes, when?      

Were you ever employed here? Yes No If yes, when?      

Have you ever been convicted of any law violation (except a minor traffic violation)? Yes No
If yes, please explain:      

A “yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are
applying will be considered.

Are you now, or do you expect to be engaged in any other business or employment? Yes No

If yes, please explain:      

Position Information
Position Applied For:       Available Start Date:      

Salary Desired:       Please check one: Full-time Part-time Contract

Days You Can Work: Mon Tue Wed Thu Fri Hours:      

How did you hear about this position?      

If referred by an employee, please provide their name:      

Education I do not have a high school diploma I have a GED

High School:       City:       State:       Grad Date:      

Undergraduate:       City:       State:       Grad Date:      

Degree Earned:       Subjects Studied:      

Graduate:       City:       State:       Grad Date:      

Degree Earned:       Subjects Studied:      

Post-Graduate:       City:       State:       Grad Date:      

Degree Earned:       Subjects Studied:      

Business or Tech School:       City:       State:       Grad Date:      

Degree Earned:       Subjects Studied:      

Special Skills
What skills or additional training to you have that are related to the job for which you are applying?

     

What machines or equipment can you operate that are related to the job for which you are applying?

     

References
Are you presently employed? Yes No May we contact your present employer? Yes No

Have you ever been fired or asked to resign from a job? Yes No

If yes, please explain:      

Business References (Give 3 References, not relatives)

Name:       Company:      

Title:       Phone:       Email:      

Name:       Company:      

Title:       Phone:       Email:      

Name:       Company:      

Title:       Phone:       Email:      

Work History
List names of employers with present or last employer listed first. Account for all periods of time, including military
service and any period of unemployment. If self-employed, give firm name and supply business references. Provide
telephone numbers and names of individuals to contact.

Company:       Phone:      

Address:       City, State Zip:      

Job Title:       Start Date:       End Date:      

Supervisor Name:       Supervisor Title:      

Were you: Hourly Salaried Consultant Starting Salary:       Ending Salary:      

Responsibilities:      

Reason for Leaving:      

Company:       Phone:      

Address:       City, State Zip:      

Job Title:       Start Date:       End Date:      

Supervisor Name:       Supervisor Title:      

Were you: Hourly Salaried Consultant Starting Salary:       Ending Salary:      

Responsibilities:      

Reason for Leaving:      

Company:       Phone:      

Address:       City, State Zip:      

Job Title: Start Date:       End Date:      

Supervisor Name:       Supervisor Title:      

Were you: Hourly Salaried Consultant Starting Salary:       Ending Salary:      

Responsibilities:      

Reason for Leaving:      

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand
that false or misleading information in my application or interview may result in my release.

Signature: Date:
 AFFIDAVIT
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I CERTIFY that all information provided in this employment application is true and complete. I understand that any
false information or omission may disqualify me from further consideration for employment and may result in my
dismissal if discovered at a later date.

I UNDERSTAND that Company Name may request an investigative consumer report from a consumer reporting
agency. This report may include information as to my character, reputation, personal characteristics and mode of
living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a
right to make a written request within a reasonable time for the disclosure of the name and address of the consumer
reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.

I AUTHORIZE the investigation of any or all statements contained in this application and also authorize any person,
school, current employer (except as previously noted), past employers and organizations from any legal liability in
making such statements.

I UNDERSTAND THAT THIS APPLICTION DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR
GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND
THAT I HAVE BEEN HIRED AT THE WILL FOR THE EMPLOYER AND MY EMPLOYMENT MAY BE
TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.

Signature Date: