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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
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
Salary Desired
Are you applying for
- Full-Time
- Part-Time
- Temporary
Referred By
Have you worked for this company before?
- Yes
- No
If yes, where?
If yes, when?
If related to anyone in this organization, give name.

Former Employers
List below previous employers, starting with the last one first.
Dates (MO/YR - MO/YR) Employer Name & Address Phone # Salary Reason for Leaving
U.S. Military Service
Dates (MO/YR - MO/YR) Branch Highest Rank Duty Specialty Salary
Driving & Vehicle Operation
Applicant to answer ONLY if applying as a Driver or Vehicle Operator.
Check the types of vehicles you are qualified, through experience to operate.
- Passenger Car
- Light Truck
- Heavy Truck or Tractor
Other
Driver's License No.
Date Expires
Ever been suspended or revoked?
- Yes
- No
Do you have auto insurance?
- Yes
- No
Has it ever been cancelled or renewal refused?
- Yes
- No
How many convictions for moving violations within the past three years?

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 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.
Date
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)

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Application for Employment

Step 1 of 5

Education

Experience

Former Employers

Driving & Vehicle Operation

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

Dates (MO/YR - MO/YR)	Branch	Highest Rank	Duty Specialty	Salary