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1 Personal
2 Position
3 Availability
4 Automobile
5 Education
6 Employment
7 References
8 Submit
Personal Information
First Name
Last Name
Address
City
Zip Code
Phone
Mobile Phone
U.S. Citizen?
Social Security Number
Have You Ever Been Convicted Of A Felony?
If Selected For Employment Are You Willing To Submit to a Pre-Employment Drug Screening Test and Background Check?
Are you 18 Years of Age or Older?
Personal I.D. / Driver License No.
If you are under 18, can you furnish a work permit?
Position
Position You Are Applying For?
Desired Employment
Available Start Date
date_range
Shift Availability
SundayFrom
access_time
MondayFrom
access_time
TuesdayFrom
access_time
WednesdayFrom
access_time
ThursdayFrom
access_time
FridayFrom
access_time
SaturdayFrom
access_time
SundayTo
access_time
MondayTo
access_time
TuesdayTo
access_time
WednesdayTo
access_time
ThursdayTo
access_time
FridayTo
access_time
SaturdayTo
access_time
Number of Shifts Desired?
Automobile Information
Can you drive a manual transmission?
Do you have negative remarks on your driving record?
If yes, please describe:
0 /
Education
School Name (1)
Location (1)
Years Attended (1)
Degree Received (1)
Major (1)
School Name (2)
Location (2)
Years Attended (2)
Degree Received (2)
Major (2)
Academic Achievements & Activities
Please list sporting activities, academic achievements, memberships, or any other extracurricular activity you would like to share:
0 /
Employer (1)
Employer Name
Job Title
Start Date
date_range
End Date
date_range
Work Phone No.
Starting Pay Rate
Ending Pay Rate
Address
City
Zip Code
Employer (2)
Employer Name
Job Title
Start Date
date_range
End Date
date_range
Work Phone No.
Starting Pay Rate
Ending Pay Rate
Address
City
Zip Code
References
Name
Title
Company
Phone No.
Name
Title
Company
Phone No.
Signature Disclaimer / Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this 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 authors and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume 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 organization 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 of the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that is 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.

I understand that I may be required to have a personal background check and take one or more physical exams, blood tests and/or drug screening test(s) as a condition of hiring or continued employment. I agree to consent to take test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising with the use of such tests.

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 identify and legal authorization to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.

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.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Full Name
Today's Date
date_range
Signature
(Sign Here)
Clear Signature
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