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NOTICE: Applicant should read the following information carefully BEFORE filling out any of the questions on this form. Title VII of the Civil Rights Act of 1964, as amended, prohibits discrimination in employment because of race, color, sex, religion, or national origin. It is also illegal to discriminate in employment of persons because of their age if over forty.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.
Name*
First Middle Last Social Security Number
Present Address*
Street Address Address Line 2 City State ZIP Code
How long have you lived at this address?
Years*
Months*
Phone*
Previous Address*
Street Address Address Line 2 City State ZIP Code
How long have you lived at this address?
Years*
Months*

Position Applied For*
Date You Can Start*
MM slash DD slash YYYY
Salary Desired*
If no answer, type 0
Are you applying for*
- Full-Time
- Part-Time
- Temporary
Referred By*

If no answer, type NONE
Have you worked for this company before?*
- Yes
- No
If yes, when and where? (Date & Location)*

If no answer, type NONE
If related to anyone in this organization, give name.*

If no answer, type NONE

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 that the Company has the same right. No one other than the General Manager of the Company has the authority to modify this relationship or 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 a drug test at any time and also reserves the right to require me to submit to an alcohol test and/or medical examination to the extent permitted by law. I understand that a confirmed positive test or my refusal to submit to such testing is grounds for dismissal.

I authorize the Company to investigate my driving record, my criminal record, references provided by me, and my credit history. 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 may contact previous employers, and I authorize those employers to disclose to the Company all records and other information pertinent to my employment with them. I also authorize the Company to provide truthful information concerning my employment with it to my future prospective employers, and I agree to hold it harmless for providing such information.

I certify that all of the information I provide in my resume and in any interview will be true and accurate. I understand that if I am employed and any such information is later found false or misleading in any respect, I may be dismissed.

This company intends to check and hold you responsible for the accuracy of the statements you make on this application. This application will receive consideration for sixty (60) days. If you have not heard from the Company within sixty (60) days and wish to receive further consideration for employment, you must reapply in person.
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THIS STATEMENT.
Date
MM slash DD slash YYYY
Signature of Applicant

Name & Location	From (Month/Year)	To (Month/Year)	Graduate? (Y or N)

Name & Location	From (Month/Year)	To (Month/Year)	Graduate? (Y or N)

Name & Location	From (Month/Year)	To (Month/Year)	Graduate? (Y or N)

Name & Location	From (Month/Year)	To (Month/Year)	Graduate? (Y or N)

Dates (MO/YR - MO/YR)	Employer Name & Address	Phone #	Salary	Reason for Leaving

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