Career Opportunities Form

Last Name: *

First Name: *

Middle Name:

Home Address: *

City:

State

Zip Code:

How long have you lived at this address?

Yrs.

Mths.

Last 4 Digits of SSN:

Home Phone:

Cell Phone:

Email Address: *

Position applied for:

Available to work:

Full-Time

Part-Time

Temporary

Date available to start work:

If you are under age 18, can you provide a work permit if offered a job?

N/A

Yes

No

If offered a job, can you prove your legal authorization to live and work in the United States?

Yes

No

Have you ever been convicted of a criminal offense (felony or misdemeanor)? (Convictions for misdemeanor marijuana related offenses that are more than two-years old need not be listed).

Yes

No

If yes, state the nature of the crime(s), when and where convicted, and disposition of the case:

Note: No applicant will be denied employment solely on the grounds of a conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position applied for may, however, be considered.

Have you ever applied for a position with or worked for this Company before?

Yes

No

If yes, specify dates: From:

To

High School

Name of School and Address

Major

No. of Years Completed

Did you Graduate?

Yes

No

College

Name of School and Address

Major

No. of Years Completed

Did you Graduate?

Yes

No

Graduate Degree

Name of School and Address

Major

No. of Years Completed

Did you Graduate?

Yes

No

Vocational or Business

Name of School and Address

Major

No. of Years Completed

Did you Graduate?

Yes

No

List any professional licenses or certificates relevant to the position you are applying for:

Type

Organization or State Issued

Date Issued

Type

Organization or State Issued

Date Issued

Type

Organization or State Issued

Date Issued

Please list your present and past work experience for the last 10 years, beginning with your most recent position. You may include volunteer activities on a separate sheet of paper.

Name of Employer:

From

Month

Year

To

Month

Year

Pay

Starting:

Final:

Address:(Street, City & State)

Telephone:

Position:

Supervisor:

Reason for Leaving

May we contact this employer?

Yes

No

Name of Employer:

From

Month

Year

To

Month

Year

Pay

Starting:

Final:

Address:(Street, City & State)

Telephone:

Position:

Supervisor:

Reason for Leaving

May we contact this employer?

Yes

No

Name of Employer:

From

Month

Year

To

Month

Year

Pay

Starting:

Final:

Address:(Street, City & State)

Telephone:

Position:

Supervisor:

Reason for Leaving

May we contact this employer?

Yes

No

Please identify and explain all periods of unemployment in excess of one month during the past 10 years:

Period of Unemployment:

From

To

Reason for Unemployment

Have you ever used any other name during employment or school other than that used on this application?

Yes

No

If yes, please specify the name you were employed or enrolled under:

Are you able to perform the essential duties of the position for which you are applying, either with or without reasonable accommodations?

Yes

No

If no, describe the functions that cannot be performed?

Note: We comply with the Americas with Disability Act (ADA) and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.

Are you a veteran of the United States military service?

Yes

No

If yes, please state branch of service:

Please list any job-related professional, trade, business or civic activities, organizations and associations. (You may omit those which indicate race, color, religion, national origin, ancestry, sex, age, or the existence of a disability):

Please provide the names, addresses, and telephone numbers of at least two professional references who are not related to you:

I understand that any offer of employment regarding certain job positions may be conditioned on satisfactory completion of a medical examination and/or a drug and alcohol screen. I agree to sign a release of medical information authorization form and to submit to a medical examination and/or drug and alcohol screen should the Company condition my offer of employment upon successful completion of such an examination or screening.
I certify, under penalty of perjury, that all of the above information is true and complete, and I understand that any misrepresentation, falsification or omission of information may result in the denial of employment or, if hired, may result in termination.
I authorize the Company to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment. I further authorize the listed employers, schools and professional/personal references to give the Company (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have.
I expressly agree and understand that, if employed, my employment, having no specific term, is based upon mutual consent and may be terminated at will, with or without cause or notice, by either party (the Company or me). I also understand that this aspect of my employment, which includes the Company's right to demote or otherwise discipline with or without cause or notice, may not be changed, modified, amended or rescinded except by an individual written agreement signed by both me and the President of the Company.
Except as required in the performance of my duties, I understand and agree that I will not at any time during or after my employment use, disclose or disseminate any confidential information or any other information of a secret, proprietary, or generally undisclosed nature relating to the Company, or its products, customers, employees, plans or procedures. I agree to deliver to the Company any and all copies of confidential information, or other Company property, upon termination of the employment relationship or at any time upon the Company's request. I also agree not to solicit clients or employees of the Organization either during my employment or after my employment termination.
I acknowledge that I have read all of the above statements and that I understand them. In addition, the statements above supersede and replace any prior understandings or discussions I have had with the Company and set forth the complete agreement between me and the Company regarding these matters.

Signature of Applicant *

Date *