Employment Application

Please Answer All Questions. Résumés Are Not A Substitute For A Completed Application

We are an equal opportunity employer. Applicants are considered for positions without regard to race, religion, sex, national origin, age, disability, or any other category protected by applicable federal, state, or local laws.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.

Applicant Contact Information

Name:		Email Address:
Phone:		Alternate Phone:
Present Address:		Apt. # or Suite:
City:		State/Zip Code:
How long have you lived there?

Applicant Job Inquiry Information

Position Applying For:		Scheduling Availability: Please select all of the shifts you can work below. Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Location(s):
Desired Salary/ hourly rate:
Date on which you can start work if hired:
If under the age of 18, can you produce the necessary work certificate at the time of employment? Yes No
Type of employment desired? Full Time Part Time
Have you ever applied to this company? Yes No
If yes, when and where did you apply?
Have you ever been employed by this company? Yes No
If Yes, provide dates of employment, location, and reason for separation from employment.

Education

High School:	From:	To:
Did you graduate? Yes No
College:	From:	To:
Did you graduate? Yes No
Other:	From:	To:
Did you graduate? Yes No
If applicable, list below any other names by which you have been known which may be necessary to allow us to confirm your work and educational record. For example, change of name, use of an assumed name, nickname, etc.

Business References

Please list three professional references

Full Name:		Relationship:
Company:		Phone:
Address:
Full Name:		Relationship:
Company:		Phone:
Address:
Full Name:		Relationship:
Company:		Phone:
Address:

Previous Employment

Company 1:		Phone:
Address:		Supervisor:
Job Title:		Starting Salary:
Ending Salary:		Responsibilities:
From / To:	/	Reason for leaving:
May we contact your previous supervisor for a reference? Yes No
Company 2:		Phone:
Address:		Supervisor:
Job Title:		Starting Salary:
Ending Salary:		Responsibilities:
From / To:	/	Reason For Leaving:
May we contact your previous supervisor for a reference? Yes No
Company 3:		Phone:
Address:		Supervisor:
Job Title:		Starting Salary:
Ending Salary:		Responsibilities
From / To:	/	Reason for leaving
May we contact your previous supervisor for a reference? Yes No

Criminal convictions or arrests will not automatically disqualify an applicant from a particular job. The Company will consider the nature of the crime, its seriousness, the substantial relation to the position’s functions and qualifications, the number of occurrences, the applicant’s age at the time of the crime, the time elapsed since the crime, the applicant’s entire work and educational history, employment references and recommendations, and the business necessity of any exclusion when required by law.

INSTRUCTIONS FOR ANSWERING THE NEXT TWO QUESTIONS
Do not include convictions that were sealed, eradicated, erased, annulled by a court, or expunged, or convictions that resulted in referral to a diversion program. Do not include misdemeanor marijuana-related convictions that are more than two (2) years old or misdemeanor convictions for which probation was successfully completed or otherwise discharged and the case was judicially dismissed.

Have you ever plead guilty or no contest to, or been convicted of any criminal offense other than the applicable exceptions listed above?
Yes No

Have you ever been arrested for any matters for which you currently are out on bail or on your own recognizance pending trial?
Yes No

Have you ever initiated an act of violence in the workplace?
Yes No

If Yes, please provide the date(s) and explain so that individual circumstances can be considered. (A “Yes” answer will not necessarily disqualify you from employment.)

CRIMINAL OFFENSES ONLY:
If you answered Yes, to either of the above two questions, please provide the date(s) and explain in accordance with the above instructions so that individual circumstances can be considered.

APPLICANT CERTIFICATION
I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

If employed by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement, as well as an agreement to arbitrate.

I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY.

IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.

I authorize the Company or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information.

If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to work in the United States.

Applicant Signature:

Date:

If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or legal guardian. Signature by the applicant’s parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Company personnel who need to know, the applicant, and the applicant’s legal guardian.

Parent/Legal Guardian Witness:

Date:

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, & COMPLETE.