Have you been convicted of or pled guilty to a felony or misdemeanor other than a minor traffic-related infraction ?(A conviction or plea will not necessarily disqualify you from consideration for employment. The effect of a conviction will be assessed with respect to time, circumstances, seriousness of the offense, and job responsibilities and duties. However your failure to list a conviction will disqualify you from consideration for employment or will result in termination of employment is subsequently discovered.) Yes No if yes, state the nature of the conviction or plea, the date, and explainName of the person to notify in case of emergencyAddressEmergency Phone No.EducationHigh SchoolName of SchoolCityStateNumber of Years CompletedGraduate? Yes No Course Pursued/ Degrees GrantedCollege or UniversityName of SchoolCityStateNumber of Years CompletedGraduate? Yes No Course Pursued/ Degrees GrantedBusiness, Trade, Technical, or Correspondence School or CollegeName of SchoolCityStateNumber of Years CompletedGraduate? Yes No Course Pursued/ Degrees GrantedList any special job-related skills, software, and qualifications acquired from education, employment, volunteer work or military service.List specific skills or office machines, tools, machinery or other equipment that you are trained on and can operate that will be helpful in performing the responsibilities of the position(s) for which you are applyingPersonal References List the name, address and telephone number of three references who are not related to you and are not previous employers.NameAddressPhoneNameAddressPhoneNameAddressPhoneDate of ApplicationSocial Security NumberPlease printName First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraรงaoCyprusCzechiaCรดte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRรฉunionSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTรผrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweร land Islands Country TelephoneIf you have resided at your present address less than three years, list your prior address:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraรงaoCyprusCzechiaCรดte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRรฉunionSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTรผrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweร land Islands Country Position(s) DesiredSalary ExpectedAre you available to work Full Time Part Time Temporary On-Call Overtime Any Shift On what date would you be available for work?Are you on a layoff and subject to recall at another employer? Yes No Have you filed an application here before? Yes No If yes, give date(s)Have you ever been employed here before? Yes No If yes, give date(s)Why did you apply for a position at [Employer]?Why do you think you would make a valuable employee of [Employer]?Are you legally authorized to work in the United States? Yes No Will you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)? Yes No Are you 18 years or older? Yes No Which of your previous jobs have you liked best?Why?Which of your previous jobs have you liked least?Why?APPLICANT'S STATEMENT (Please indicate that you have read and understand each paragraph of the Applicant's Statement by placing your initials beside each paragraph.) UntitledI certify that this application was completed by me and that all entries and information in it are TRUE and COMPLETE to the best of my knowledge. I understand that false, misleading or omitted information in my application may result in the rejection of my application, the revocation of an offer of employment, or discharge. Yes No UntitledI authorize investigation of all statements contained in this application as may be necessary in arriving at an employment decision. I understand that an investigation may be made and information may be obtained through interviews with personal references and past employers, through a credit check, a criminal history check and/or a driver's record check. This inquiry may include information as to, among other things, my character, general reputation and personal characteristics, as well as information about my work performance and workplace conduct. I consent to this investigation and to the consideration of any statements of references, former employers or others that are given in response to the inquiry. If [Employer] decides to obtain a consumer credit report, I understand that [Employer] will provide, at my request, the name and address of the reporting agency so I may obtain from such reporting agency the nature and substance of information contained in such report. Yes No UntitledI hereby release all parties, including but not limited to [Employer] personal references and previous employers, from liability for any injury or damage that may result from their furnishing information concerning me or any action [Employer] takes on the basis of such information. Yes No UntitledI understand that, if I am offered a job, as a condition of beginning my employment, I may be required to undergo a physical examination and drug screen, and I hereby authorize any doctor, hospital, clinic, laboratory and/or other medical facility to furnish any medical information with reference to me as may be necessary in conjunction with that examination and related considerations. Yes No UntitledI understand that, according to federal law, all individuals who are hired must, as a condition of employment, produce certain documentation to verify their identity and United States citizen status or, if aliens, their legal authorization to work in the United States. As a consequence, I understand that any offer of employment to me is contingent upon my ability to produce the required documentation within the time period required by law. Yes No UntitledI understand that this application is not, and is not intended to be, a contract of employment and that any resulting employment is for no fixed period of time and is terminable at any time and for any reason by me or by [Employer]. I further understand that statements which may be contained in policies, practices, handbooks or other material do not create any guarantee of employment and that [Employer] has the right to modify, amend or terminate policies, practices, benefits plans or other programs within the limits and requirements imposed by law. I understand that no representative of [Employer], other than an officer, has the authority to enter into any agreement for any specific period of time or to make any agreement contrary to the foregoing and that any such agreement must be in writing to be binding. Yes No UntitledI understand that, upon employment, I will sign an agreement relating to confidential information, if required. Yes No UntitledI certify that I am not bound by any employment contract or non-competition agreement that would be breached by any employment that might be offered to me by the Company, nor am I in possession of nor will I at any time reveal to the Company, under any circumstances, any proprietary or confidential information that is the subject of any contract, non- disclosure agreement or prior work relationship involving any other person or entity. Yes No Signature of ApplicantDate MM slash DD slash YYYY THIS APPLICATION WILL NOT BE CONSIDERED ACTIVE AFTER 60 DAYS BUT WILL BE RETAINED PURSUANT TO LEGAL REQUIREMENTS FOR ONE YEAREMPLOYMENT RECORD Starting with your present or most recent job, list all your employment experience for at least the last 15 years. You may include job-related military service assignments and volunteer activities that reflect your qualifications for employment.EmployerTelephoneJob TitleImmediate Supervisor:AddressEmployment DatesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Salary/Hourly RateStarting:Final:Kind of Work Performed/Reason Employment EndedEmployerTelephoneJob TitleImmediate Supervisor:AddressEmployment DatesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Salary/Hourly RateStarting:Final:Kind of Work Performed/Reason Employment EndedEmployerTelephoneJob TitleImmediate Supervisor:AddressEmployment DatesTo MM slash DD slash YYYY From MM slash DD slash YYYY Salary/Hourly RateStarting:Final:Kind of Work Performed/Reason Employment EndedEmployerTelephoneJob TitleImmediate Supervisor:AddressEmployment DatesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Salary/Hourly RateStarting:Final:Kind of Work Performed/Reason Employment EndedIf you need additional space, please continue on a separate sheet of paperMay we contact the employers listed above? Yes No If no, indicate which one(s) you do NOT wish us to contact and state the reason why you prefer that we do not contact the employer(s).Have you ever been discharged, permitted to resign rather than be discharged, or asked to resign from any position? Yes No If yes, please state the employer, and the reason for the discharge or resignation.Captcha Δ