Employment Application

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended to evaluate suitability for employment. It is the policy of the company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, national origin, citizenship, disability, veteran status, or any other status protected under local, state or federal law. It is also the policy of the company to have the option of conducting pre-employment screening before a job offer is made. If a job offer is made, employment may be contingent upon the successful completion of a pre-employment drug screening and/or medical examination. This application will remain active for 3 years.

Personal Information

First Name:
Middle Initial:
Last Name:
Home Phone:
Work Phone:
Cell Phone:
Email Address:

Current Address

Street:
City:
State:
Zip Code:
Since (Mo/Yr):

Prior Address (1)

Street:
City:
State:
Zip Code:
Since (Mo/Yr):
To (Mo/Yr):

Prior Address (2)

Street:
City:
State:
Zip Code:
Since (Mo/Yr):
To (Mo/Yr):

High School

School:
City:
State:
Diploma:	No Yes

Undergrad School

School:
City:
State:
Diploma:	No Yes
Deg/Cert/Dip:
Area of Study:

Grad School

School:
City:
State
Diploma:	No Yes
Deg/Cert/Dip:
Area of Study:

Other School

School:
City:
State:
Diploma:	No Yes
Deg/Cert/Dip:
Area of Study:

Most Recent Employer

Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Pay Upon Leaving:
Supervisor:
Duties:
Reason For Leaving:

Prior Employer (1)

Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Pay Upon Leaving:
Supervisor:
Duties:
Reason For Leaving:

Prior Employer (2)

Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Pay Upon Leaving:
Supervisor:
Duties:
Reason For Leaving:

Prior Employer (3)

Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Pay Upon Leaving:
Supervisor:
Duties:
Reason For Leaving:

Job-related Skills

	Please answer the following questions if the position you are applying for requires driving a motor vehicle:
1.	Do you have a valid driver's license?
	No Yes
	If yes, Driver's License Number:
	Date of Issue:
Skills
Professional Designations

Reference (1)

Name:
Address:
Telephone:
Relationship:
Years Acquainted:

Reference (2)

Name:
Address:
Telephone:
Relationship:
Years Acquainted:

Reference (3)

Name:
Address:
Telephone:
Relationship:
Years Acquainted:

Reference (4)

Name:
Address:
Telephone:
Relationship:
Years Acquainted:

Applicant's Certification Agreement

1.	I authorize the investigation of all statements contained in this application and release from all liability any persons or employers supplying such information, and I also release the company from all liability that might result from making the investigation.
2.	I certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application (or on any required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.
3.	I agree, if I am offered and accept a position, to conform to all existing and future Company rules and regulations and I understand that the Company reserves the right to change wages, hours and working conditions as deemed necessary. *I ALSO UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE AT-WILL, MEANING THAT EITHER PARTY CAN END THE EMPLOYMENT RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON.*
4.	I understand that any employment offer is contingent upon my providing, within three (3) working days of employment, valid proof od identity and eligibility to work in order to comply with the Immigration Reform and Control Act of 1986.
5.	I have read and reviewed the information provided in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely and fully.
6.	I understand that by typing my name in the signature box below and submitting this application electronically, this becomes a legal and binding contract.

	Type Name in Signature Box:
	Today's Date: 2010-03-11 22:44:40 CST