Employment Application

"*" indicates required fields

Step 1 of 5

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Name*

First Middle Last

Address*

Street Address City State ZIP Code

Email*

Phone*

Position Applied for*

Shift preferred*

Any

Special training or skills (languages, machine operation, etc.) that would benefit you in the job for which you are applying:

Would you accept full-time work?*

Yes

Would you accept part-time work?*

Yes

On what date would you be available for work?*

Have you ever been employed here?*

Yes

If yes, dates

Are you lawfully authorized to work in the United States?*

Yes

If you are under 18 years old, can you furnish a work permit if required?*

N/A

Yes

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)?*

This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Yes

Need more information about the job's essential functions to respond.

Notice to Rhode Island applicants: This Company is subject to the state's workers compensation laws (Chapters 29-38) unless otherwise noted further below:

Starting with your most recent school attended, provide the following information.

School Name

City and State

# Years Completed

Completed

Diploma

GED

Degree

Certification

Other

Degree / Certificate / Other Name

Major

GPA / Class Rank

School #2

City and State

# Years completed

Completed

Diploma

GED

Degree

Certification

Other

Degree / Certification / Other Name

Major

GPA / Class Rank

Employment History

Starting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis.

Employer #1*

Telephone*

Address*

Street Address City State

Starting job title/final job title*

Dates Employed*

Immediate supervisor and title*

for most recent position you held

May we contact for reference?*

Yes

Later

Summarize the type of work performed and job responsibilities.*

Employer #2

Telephone

Address

Street Address City State

Starting job title/final job title

Dates Employed

Immediate supervisor and title

for most recent position you held

May we contact for reference?

Yes

Later

Summarize the type of work performed and job responsibilities.

Employer #3

Telephone

Address

Street Address City State

Starting job title/final job title

Dates Employed

Immediate supervisor and title

for most recent position you held

May we contact for reference?

Yes

Later

Summarize the type of work performed and job responsibilities.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE APPLICANT STATEMENT.

Terms*

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct.

I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional, employers, public agencies, licensing authorities, and educational Institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using truthful and non-defamatory Information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law.

I understand that this application remains current for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If l am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may he 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 supervisor or representative of the employer Is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will he required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an 1-9 Form In this regard.

I understand that reasonable safeguards will he taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer's affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer.

This Company does not tolerate unlawful discrimination In its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex (including pregnancy, sexual orientation and gender identity), race, color, religion, national origin, citizenship, age. disability, genetic information, or any other protected status under applicable federal, state, or local law.

Mandatory Employer Disclosures

Notice to Illinois applicants: Please be advised pursuant to Illinois law, applicants are not obligated to disclose expunged juvenile records of adjudication, arrest, or conviction. Notice to Indiana applicants: his company complies with Indiana law prohibiting smoking in enclosed areas within places of employment. Notice to Maryland applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NO REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OP A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING S100. Notice to Massachusetts applicants: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Notice to North Dakota applicants This company complies with North Dakota law prohibiting smoking within 20 feel of entrance and inside places of employment. Notice to Rhode Island applicants: This company complies with Rhode Island law prohibiting smoking In enclosed are-as within places of employment.

Signature of Applicant*

Date*

Employment Application

Employment History

Starting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis.

DO NOT SIGN UNTIL YOU HAVE READ THE APPLICANT STATEMENT.

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