* Required Fields APPLICATION FOR EMPLOYMENT * Required Fields

Please review job posting carefully; additional forms may be required. Incomplete applications may be cause for disqualification. Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify a representative of the Human Resources Department.

* Position(s) - Make A Selection -

PERSONAL INFORMATION

Name   * First Middle * Last E-Mail

Address   * Street * City * State * Zip

Contact   * Phone Cell Pager Phone Cell Pager

GENERAL INFORMATION

If you are under 18 and it is required, can you furnish a work permit? Yes No If no, please explain * Have you ever been employed here before? Yes No * Are you legally eligible for employment in this country? Yes No Date available for work Type of employment desired  Full-Time    Part-Time    Temporary    Seasonal   * Are you able to meet the attendance requirements of the position? Yes No * Have you ever been convicted of a crime in the last (7) years? Yes No If yes, please explain Conviction will not necessarily be a bar to employment. Each instance will be considered in relation to the position for which you are applying. Driver's license number if driving is an essential job function State

EMPLOYMENT HISTORY

Please provide us with the following information for your past (4) employers, assignments or volunteer activities, starting with the most recent.  Employer #1 From To Employer Telephone Job Title Address Immediate Supervisor Summarize the nature of work performed and job responsibilities Supervisor's Title Reason for leaving Hourly Rate/Salary Start $ Per Final $ Per  Employer #2 From To Employer Telephone Job Title Address Immediate Supervisor Summarize the nature of work performed and job responsibilities Supervisor's Title Reason for leaving Hourly Rate/Salary Start $ Per Final $ Per  Employer #3 From To Employer Telephone Job Title Address Immediate Supervisor Summarize the nature of work performed and job responsibilities Supervisor's Title Reason for leaving Hourly Rate/Salary Start $ Per Final $ Per  Employer #4 From To Employer Telephone Job Title Address Immediate Supervisor Summarize the nature of work performed and job responsibilities Supervisor's Title Reason for leaving Hourly Rate/Salary Start $ Per Final $ Per

SKILLS and QUALIFICATIONS

Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

EDUCATIONAL BACKGROUND (if job related)

NAME AND LOCATION YEARS COMPLETED DID YOU GRADUATE? COURSE OF STUDY HIGH SCHOOL LOCATION   YES NO   COLLEGE LOCATION   MAJOR DEGREE   OTHER LOCATION   YES NO

REFERENCES

NAME TELEPHONE (XXX) XXX-XXXX YEARS KNOWN

COMPLETE AND ACCURATE INFORMATION

I UNDERSTAND THAT IF I AM EMPLOYED, ANY MISREPRESENTATION OR MATERIAL OMISSION MADE BY ME ON THIS APPLICATION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION OR IMMEDIATE DISCHARGE FROM THE EMPLOYER'S SERVICE, WHENEVER IT IS DISCOVERED. I GIVE THE EMPLOYER THE RIGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES, EMPLOYERS, EDUCATIONAL INSTITUTIONS AND OTHERWISE VERIFY THE ACCURACY OF THE INFORMATION CONTAINED IN THIS APPLICATION. I HEREBY RELEASE FROM LIABILITY THE EMPLOYER AND ITS REPRESENTATIVES FOR SEEKING, GATHERING AND USING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION. THE EMPLOYER DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THIS APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FROM CONSIDERATION FOR EMPLOYMENT ON A BASIS PROHIBITED BY LOCAL, STATE, OR FEDERAL LAW. THIS APPLICATION IS CURRENT FOR ONLY 60 DAYS AT THE CONCLUSION OF THIS TIME. IF I HAVE NOT HEARD FROM THE EMPLOYER AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT, IT WILL BE NECESSARY TO FILL OUT A NEW APPLICATION. IF I AM HIRED, I UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, EXCEPT AS MAY BE REQUIRED BY LAW. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF THE EMPLOYER, OTHER THAN AN AUTHORIZED OFFICER, HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE IN WRITING AND SIGNED BY AND AUTHORIZED OFFICER. I UNDERSTAND IT IS THIS COMPANY'S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIDUAL, WITH A DISABILITY BECAUSE OF THAT PERSON'S NEED FOR REASONABLE ACCOMMODATIONS AS REQUIRED BY THE ADA. I ALSO UNDERSTAND THAT IF I AM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION. I REPRESENT AND WARRANT THAT I HAVE READ AND FULLY UNDERSTAND THE FORGOING AND SEEK EMPLOYMENT UNDER THESE CONDITIONS.