Employment Application We are committed to a policy of Equal Employment Opportunity and will not discriminate on any legally recognized basis, including but not limited to race, age, color, religion, sex, marital status, national origin, citizenship, ancestry, handicap or disability or veteran status. PERSONAL BACKGROUNDName(Required) First Middle Last Present Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permanent Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Referred by:Position Applying For(Required)Date you can start(Required) Month Day Year Pay Rate Desired(Required)Are you employed?(Required)If so, may we inquire of your present employer?Ever applied to this company before?(Required)Where?When?Are you willing to work overtime?(Required) Yes No U.S. Military or Naval ServiceRankIf driving is a requirement of the job for which you are applying, do you have a current, valid driver's license? Yes No If driving is a requirement of the job for which you are applying, continued employment is contingent on you maintaining a current driver's license. If a minor, can you produce the age/work certificate necessary to obtain employment? Yes No Are you able, at the time of employment, to submit verification of your legal right to work in the U.S.?Verification and completion of the 1-9 form must be submitted no later than three business days after date of hire. Yes No Educational Background Level of Education Name & Location of School Highest Grade Completed Major Area of Study Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Specialized Technical Skillsi. e. computer programmer/language, equipment operation, special tools or machines usedWork ExperienceList below last four employers, starting with your present or last place of employment. You may include in such history any verified work performed on a volunteer basis. From To Employer Name Position Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. ReferencesGive the names of three persons not related to you, whom you have known at least three years. Name Occupation Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. APPLICANT'S STATEMENT In signing this application, I certify that all of the foregoing information is a complete and accurate statement of the facts and understand that if any misrepresentation, omission or falsification be discovered, it will constitute grounds for dismissal. I hereby authorize you to conduct any investigation necessary concerning any part of my background related to the position I am seeking. I release all parties from any liability in connection with the provision and use of such information. I understand and agree that, if employed by this organization, I will abide by its rules and regulations which I understand are subject to change. I further understand that, if hired, my employment is for no definite period of time and may be terminated by either party at any time. Signature(Required)Date(Required) Month Day Year