Personal                                               Please print clearly                                       Date                      

First Name                 Middle              Last Name          

Street Address                Social Security    

City/State/Zip                   Phone                   

If hired, do you have a reliable means of transportation to get to work?   What is it?

Minimum hourly wage expected Are you at least 16 years old?

Are you legally eligible for employment in the U.S.? (Proof of U.S. citizenship or immigration status will be required if hired.)

Have you been convicted of a felony in the last seven years?    Are you currently on parole?

Are you currently awaiting trial?                                              

If you answered yes to any of the previous questions, state the nature of the offense and disposition of the case. Include dates and places. (Note: Felony convictions or the existence of a criminal record do not constitute an automatic bar of employment)

Employment Data
Part-Time Employment Availability

Are you currently employed?  

Have you ever worked for this organization before?  

Name any friends or relatives employed by this company:

Education
Name of High School:   Grade :    Graduated:

College: Years :  

Degree:

PLEASE READ THE FOLLOWING CAREFULLY, THEN SIGN AND DATE THE APPLICATION.

I authorize this company to make an investigation of all information contained in this employment application and I release from liability all companies and corporations supplying such information. I understand any false answers, statements, or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge. Upon termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning my employment to any potential employer. I authorize this company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any other investigative report deemed necessary through various third party sources. As required by law, upon request within a reasonable period of time, I will be notified as to the nature and scope of such investigations. I hereby agree to submit to any drug test required of me, whether prior to my employment or if employed by this company at any time thereafter. If requested, I will take a post-job offer physical examination and my employment will be conditional upon passing such examination. During such employment, in the event I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric condition that is job-related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider and a company-designated physician. I further understand this is an application for employment and that no employment contract is being offered. I understand that if I am employed, such employment is for an indefinite period of time and the company may change wages, benefits, and conditions at any time. My employment is at will. No individual with the company is authorized to change the employment-at-will status except an officer of the company, who may do so only in writing. I have read and understand the above.

Applicant’s Signature        Date