We are an Equal Opportunity Employer. All applicants are considered without regard to race, color, religion, disability, sex, national origin, age (for those over 40 or over), or any other basis protected by federal, state, or local law. This employment application is only active for 30 days. After this time a separate employment application must be submitted in order to be considered for employment.
Date:__________________
Personal Information
First Name__________________ Middle__________________ Last________________________
Street Address ___________________________ Social Security No. ________________________
City/State/Zip ________________________________ Phone (___)________________________
How did you find out about this job? __ Newspaper __ Referral __Other _______________________
If hired, do you have a reliable means of transportation? __ Yes __ No
Minimum Salary Expected ________________________ Are you at least 18 years old? __ Yes __ No
Are you legally eligible for employment in the US? __ Yes __No
Have you been convicted of a crime? __ Yes __ No If yes state the nature of the offense and disposition of
the case. (NOTE: The existence of a criminal record does not constitute an automatic bar to employment.
_____________________________________________________________________________________

Employment Data
Are you seeking: __ Temporary __ Full-time __ Part-time
What position(s) are you applying for? _______________________
What hours and shift(s) would you prefer to work? ________________________________________
What hours or shift(s) would you prefer not to work? ______________________________________
Are you will to work overtime? __Yes __ No Weekends? __ Yes __ No Holidays? __Yes __No
Are you currently employed? __Yes __No If hired when can you start? ___________________
Are you on layoff or subject to recall? __ Yes __ No
Have you ever been discharged or asked to resign from any position? __ Yes __ No If yes, please describe:
_____________________________________________________________________________________

Work History (Please list you last four employers. Begin with most recent.)

1. Company_________________________________ Phone No. with Area Code: (___)_____________
Address __________________________________ City/State/Zip ____________________________
Dates of Employment From ________ To _______ Salary Beginning _________ Ending __________
Job Title __________________________________ Supervisor’s Name and Title _________________
Describe Duties ______________________________________________________________________
Specific reason for leaving: _____________________________________________________________
2. Company_________________________________ Phone No. with Area Code: (___)_____________
Address __________________________________ City/State/Zip ____________________________
Dates of Employment From ________ To _______ Salary Beginning _________ Ending __________
Job Title __________________________________ Supervisor’s Name and Title _________________
Describe Duties ______________________________________________________________________
Specific reason for leaving: _____________________________________________________________
3. Company_________________________________ Phone No. with Area Code: (___)_____________
Address __________________________________ City/State/Zip ____________________________
Dates of Employment From ________ To _______ Salary Beginning _________ Ending __________
Job Title __________________________________ Supervisor’s Name and Title _________________
Describe Duties ______________________________________________________________________
Specific reason for leaving: _____________________________________________________________