Application for Employment Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status. Date ______________ Last name ________________________ First name ________________ Middle name________ Street Address _________________________________________________________________ City _____________________ State _______ ZIP _______ Telephone ___________________________ Social Security # ___________________________ Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.)  Yes  No Are you looking for full-time employment?  Yes  No If no, what hours are you available? ______________ Are you willing to work swing shift?  Yes  No Are you willing to work graveyard?  Yes  No Have you ever been convicted of a felony? (This will not necessarily affect your application.)  Yes  No If yes, please describe conditions. _________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Employment Desired Position applied for __________________________________________ How did you hear of this opening? __________________________________________ Have you ever applied for employment here?  Yes  No When? ___________________________________ Where?___________________________________ Have you ever been employed by this company?  Yes  No When? ___________________________________ Where?___________________________________ Are you presently employed?  Yes  No May we contact your present employer?  Yes  No Are you available for full-time work?  Yes  No Are you available for part-time work?  Yes  No Will you relocate?  Yes  No Are you willing to travel?  Yes  No If yes, what percent? __________________________ Date you can start_______________________________________________________________ Desired position________________________________________________________________ Desired starting salary___________________________________________________________ Please list applicable skills________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Education School Name and Location Year Major Degree High School ______________________________________________ _________ ______ College _________________________________________________ _________ ______ College _________________________________________________ _________ ______ Post-College _____________________________________________ _________ ______ Other Training ______________________________________ ______ _________ ______ In addition to your work history, are there are other skills, qualifications, or experience that we should consider? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please list any scholastic honors received and offices held in school. ______________________________________________________________________________ ______________________________________________________________________________ Are you planning to continue your studies?  Yes  No If yes, where and what courses of study? ______________________________________________________________________________ Employment History (Start with most recent employer) Company Name ________________________________________________________________ Address ________________________________________Telephone ______________________ Date Started ____________ Starting Wage ____________ Starting Position _______________ Date Ended _____________ Ending Wage ____________ Ending Position ________________ Name of Supervisor ____________________________________ May we contact?  Yes  No Responsibilities ________________________________________________________________ ______________________________________________________________________________ Reason for leaving ______________________________________________________________ Company Name ________________________________________________________________ Address _______________________________________ Telephone ______________________ Date Started ___________ Starting Wage ____________ Starting Position ________________ Date Ended _____________ Ending Wage ____________ Ending Position ________________ Name of Supervisor ____________________________________ May we contact?  Yes  No Responsibilities ________________________________________________________________ ______________________________________________________________________________ Reason for leaving ______________________________________________________________ Company Name ________________________________________________________________ Address _______________________________________ Telephone ______________________ Date Started ___________ Starting Wage ____________ Starting Position ________________ Date Ended ___________ Ending Wage ____________ Ending Position __________________ Name of Supervisor ____________________________________ May we contact?  Yes  No Responsibilities ________________________________________________________________ ______________________________________________________________________________ Reason for leaving _____________________________________________________________ Company Name _______________________________________________________________ Address _______________________________________ Telephone ______________________ Date Started ___________ Starting Wage ____________ Starting Position ________________ Date Ended ____________ Ending Wage ____________ Ending Position _________________ Name of Supervisor ____________________________________ May we contact?  Yes  No Responsibilities ________________________________________________________________ ______________________________________________________________________________ Reason for leaving ______________________________________________________________ Company Name ________________________________________________________________ Address _______________________________________ Telephone ______________________ Date Started ___________ Starting Wage ____________ Starting Position ________________ Date Ended ____________ Ending Wage ____________ Ending Position _________________ Name of Supervisor ____________________________________ May we contact?  Yes  No Responsibilities ________________________________________________________________ ______________________________________________________________________________ Reason for leaving ______________________________________________________________ Company Name ________________________________________________________________ Address _______________________________________ Telephone ______________________ Date Started ___________ Starting Wage ____________ Starting Position ________________ Date Ended ____________ Ending Wage ____________ Ending Position _________________ Name of Supervisor ____________________________________ May we contact?  Yes  No Responsibilities ________________________________________________________________ ______________________________________________________________________________ Reason for leaving ______________________________________________________________

References List three personal references, not related to you, who have known you for more than one year. Name ____________________________ Phone ____________________Years Known_______ Address ______________________________________________________________________ Name ____________________________ Phone ____________________Years Known_______ Address ______________________________________________________________________ Name ____________________________ Phone ____________________Years Known_______ Address ______________________________________________________________________

Emergency Contact In case of emergency, please notify: Name ______________________________________________ Phone ____________________ Address ______________________________________________________________________ Name ________________________ Phone ____________________ Address ______________________________________________________________________ Please Read Before Signing: I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application. I authorize my previous employers, schools, or persons listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees. In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of the approved documents that are required. I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statements. Signature _______________________________________________ Date_________________ Find more forms for your business at www.entrepreneur.com/formnet.