Applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or in the presence of a non-related medical condition or handicap.

Name_______________________________________________________          Date___________________

Address___________________________________________________               Phone #___________________

City_____________________ State_____ Zip__________ Social Security #_______________________  DOB_________________

Are you a citizen of the United States of America? [ ] Yes [ ] No

Have you ever used another name, AKA, or alisas? [ ] No if [ ] Yes ____________________________

Have you applied here before? [ ] Yes [ ] No When?______Position applied for?_________________

Start When_______________ [ ] Full time [ ] Part time [ ] Temporary [ ] Other__________________

EMPLOYMENT EXPERIENCE; Start with your present job or last job. Include military assignments and other volunteer activities. Exclude organizational names which indicate race, color, religion, sex, or national origin

Employer 1__________________________________________________________________________ Address___________________________________City________________State_____Zip__________ Phone #________________Supervisors’ Name_____________________________________________ Job Title______________________Reason for leaving_______________________________________ Dates of Employment: From_________To__________Salary or Hourly rate______________________

Employer 2__________________________________________________________________________ Address___________________________________City________________State_____Zip__________ Phone #________________Supervisors’ Name_____________________________________________ Job Title______________________Reason for leaving_______________________________________ Dates of Employment: From_________To__________Salary or Hourly rate_____________________

Employer 3__________________________________________________________________________ Address___________________________________City________________State_____Zip__________ Phone #________________Supervisors’ Name_____________________________________________ Job Title______________________Reason for leaving_______________________________________ Dates of Employment: From_________To__________Salary or Hourly rate______________________

EMPLOYMENT APPLICATION PART 2 EDUCATION Schools/Collages Attended: # Years Year Grad. Degree ____________________________________________________ _______ _______ ___________ ____________________________________________________ _______ _______ ___________ ____________________________________________________ _______ _______ ___________

Describe any special qualifications for this job: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

Drivers License #_______________________________State__________Expiration_______________

Are you a veteran of the U.S. Military service? [ ] Yes [ ] No

I CERTIFY that answers given herein are true and complete to the best of my knowledge. I authorize investigations of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not intended to be a contract of employment. In the event of employment, I understand that false or misleading information given on my application or interview may result in termination.

Signature___________________________________________________Date_____________________

For Personnel Department only

Remarks____________________________________________________________________________ ___________________________________________________________________________________ __________________________________________Interview report by__________________________