Date

Last Name First Name Middle Name
Street Address
City State Zip
Phone
Email
SSN

Position applied for
How did you hear of this opening?
When can you start? Desired Wage $
Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.)

Are you looking for full-time employment?

If no, what hours are you available?
Are you willing to work out of town?

Do you have any medical conditions that prevent you from lifting up to 90lbs repetitively?

Have you ever been convicted of a felony?

If yes, please describe conditions.

Education

In addition to you work history, are there other skills, qualifications, or experience that we should consider?

Employment History (Start with most recent employer)

Please list three references including how you know them and contact information

I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal. This company is hereby authorized to make any investigations of my prior educational and employment history and also conduct a criminal background check.

I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, or executive of this company, other than the president, has any authority to alter the foregoing.