Job applicants

Starting with your most recent employer, provide the following information.

Explain any gaps in your employment, other than those due to personal illness, injury or disability.
If not addressed on previous page, have you ever been fired or asked to resign from a job? Yes No This field is required
If yes, please explain:
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying.
Computer Skills (Check appropriate boxes. Include software titles and years of experience.)

	Word Processing		Years			Internet		Years
	Spreadsheet		Years			Other		Years
	Presentation		Years			Other		Years
	Email		Years			Other		Years

Starting with your most recent school attended, provide the following information.

School (include City and State)	Years Completed	Completed	GPA Class Rank	Major/Minor
		Diploma GED Degree Certificate Other
		Diploma GED Degree Certificate Other
		Diploma GED Degree Certificate Other
		Diploma GED Degree Certificate Other

List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Name	Title	Relationship to You	Telephone	Email	# of Years Known

SS#
We will use this information only for employment purposes and make resonable efforts to safeguard your privacy.

To what job-related organizations (professional, trade, etc.) do you belong?
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.

Organization	Offices Held

List special accomplishments, publications, awards, etc.
Exclude information that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.
In your current or a prior job, have you ever written instructions or directions to be followed by employees or customers?
Yes No Not Applicable This field is required
If yes, please explain:

Is there any other job-related information you want us to know about you?

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, résumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

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