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Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Email

Position Applied for:

Date Available for work?

Minimum hours a week needed?

Education

Select all that apply

Part Time
Fill in

Days available for work (Select all that apply)

If hired, do you have a reliable means of transportation to and from work?

Yes
No

If hired, would you be able to travel or work overtime as needed?

Yes
No

Have you ever been convicted of a felony or misdemeanor?

Yes
No

If yes, please explain:

I can lift 50 pounds?

Yes
No

Employer

Current

Yes
No

Company Name

Position

Supervisor Name

First

Last

Start Date

End date

Employer 1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Email of supervisor

May we contact this employer

Yes
No

Starting Salary

Ending Salary

Reason for leaving

of or committed

Previous Employer

Company Name

Position

Supervisor Name

First

Last

Start Date

End date

Employer 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Email of supervisor

May we contact this employer

Yes
No

Starting Salary

Ending Salary

Reason for leaving

Personal Reference #1 Relationship:

Name

First

Last

Phone Number

Email

Personal Reference #2 Relationship:

Name

First

Last

Phone Number

Email

Personal Reference #3 Relationship:

Name

First

Last

Phone Number

Email

Are you over 18 years of age? (You will be required to provide proof of age).

Yes
No

If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?

Yes
No

Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation

Yes
No

Please indicate that you have read and understand this statement: Equal Employment Opportunity Statement This company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. The Company desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, age or any other status protected by Federal, State or local laws. The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the company.

Yes
No

Please indicate that you have read and understand this statement: Discrimination and Sexual Harassment Policy Statement: This Company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual’s employment; (2) Submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment.

Yes
No

Please indicate that you have read and understand this statement: Disclosure to Applicants Concerning Drug/Alcohol Testing: If you are offered a position with the Company, you may be given a drug/alcohol test as a condition of employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this company. Neither the collector of specimens nor the medical professional who reviews the test results will be a company employee. The test results will be kept confidential. The individual undergoing testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen. Negative test results are required as a condition of employment.

Yes
No

Please indicate that you have read and understand this statement: Complete and Accurate Information: I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

Yes
No

Please indicate that you have read and understand this statement: At-Will Employment: I understand and agree that if I am employed, my employment will be “at-will”, which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the Company will respect my right to terminate my employment at any time, with or without cause and with or without notice. I further understand that any prior representation, whether expressed or implied to the contrary is hereby superseded and that no promise or representation contrary to the foregoing is binding on the Company unless made in writing and signed by the Company’s president.

Yes
No

Please indicate that you have read and understand this statement: Testing Authorization: If offered a position with the Company, I hereby agree to any legally permitted physical, psychological, skill, drug or medical test required by the Company as a condition of employment.

Yes
No

Please indicate that you have read and understand this statement: Investigation Authorization: I authorize investigation into all statements and references contained in this application. Said investigation may include credit, driving, criminal background, references and other background checks. By applying for this job, I also authorize post-hire investigation into my credit, driving and criminal background.

Yes
No

Please indicate that you have read and understand this statement: Company Obligation: I understand and agree that the Company’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the Company is under no obligation to hire me as the result of accepting this completed application.

Yes
No

Please indicate that you have read and understand this statement: If hired, I will be under a 60 trial period.

Yes
No

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