APPLICATION FOR EMPLOYMENT

Applications are received and employees are hired without regard to race, creed, color, sex, religion, age, genetic information, national origin, physical
or mental handicap, disability, veteran’s status, citizenship status, or any other protected classes under state, local or county regulations. The receipt of
this application does not mean that job openings exist and does not obligate us in any way. We appreciate your interest in our organization. This is a
Drug-Free Workplace Offering Equal Employment Opportunities

Your Personal Information

Las Name: Required value. Firs Name: Required value. Middle Name: Required value.

Address: Required value. City: Required value. State: Required value. Zip Code: Required value.

Country: Required value. Email Address: Required value.

Home Telephone*: Required value. Cell Phone*: Required value.

Preferred method of contact: Home Phone Cell E-mail

Employer:

Dates Employed
From [Mo/Yr]]: To [Mo/Yr]]: Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings

Starting: Final:

Job Title:

Summary of Work Performed and Job Responsiblities

Supervisor’s Name:

Resigned or Terminated - State Reason:

____________________________________________________________________________________________________________________________

Employer:

Dates Employed
From [Mo/Yr]]: To [Mo/Yr]]: Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings

Starting: Final:

Job Title:

Summary of Work Performed and Job Responsiblities

Supervisor’s Name:

Resigned or Terminated - State Reason:

____________________________________________________________________________________________________________________________

Employer:

Dates Employed
From [Mo/Yr]]: To [Mo/Yr]]: Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings

Starting: Final:

Job Title:

Summary of Work Performed and Job Responsiblities

Supervisor’s Name:

Resigned or Terminated - State Reason:

____________________________________________________________________________________________________________________________

Employer:

Dates Employed
From [Mo/Yr]]: To [Mo/Yr]]: Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings

Starting: Final:

Job Title:

Summary of Work Performed and Job Responsiblities

Supervisor’s Name:

Resigned or Terminated - State Reason:

____________________________________________________________________________________________________________________________

Employer:

Dates Employed
From [Mo/Yr]]: To [Mo/Yr]]: Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings

Starting: Final:

Job Title:

Summary of Work Performed and Job Responsiblities

Supervisor’s Name:

Resigned or Terminated - State Reason:

____________________________________________________________________________________________________________________________

Employer:

Dates Employed
From [Mo/Yr]]: To [Mo/Yr]]: Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings

Starting: Final:

Job Title:

Summary of Work Performed and Job Responsiblities

Supervisor’s Name:

Resigned or Terminated - State Reason:

____________________________________________________________________________________________________________________________

Employer:

Dates Employed
From [Mo/Yr]]: To [Mo/Yr]]: Phone:

Hourly Rate, Weekly Salary or Other Weekly Earnings

Starting: Final:

Job Title:

Summary of Work Performed and Job Responsiblities

Supervisor’s Name:

Resigned or Terminated - State Reason:

Tell Us About Yourself

You must answer every question on this application. If a question does not apply, put “N/A.” Please print.

What position are you applying for?

What is your salary expectation? $: When can you start work? (Date):

How were you referred to us?: (If you were referred by a person, please provide the name)

Have you completed an application here before? Yes No If yes - date/location:

Have you been employed here before? Yes No If yes - date/location:

When are you available to work? (Check any that apply): Full Time: Part Time Temporary Nights Weekends

Are there any days or times during the week that you are not available to work? Yes No

(Reasonable accommodation of religious needs that do not create an undue hardship will be considered, if applicable.)

If yes, please list the days/times you are not available to work

If necessary, can you provide proof that you are over any minimum work age requirement? Yes No

Are you willing to work overtime? Yes No - Do you have steady transportation to work? Yes No

Can you travel, if required? Yes No - What percentage of time?

Are you on a layoff and subject to recall? Yes No - May we contact your present employer? Yes No

How much time have you lost from work during the past 12 months?

Are you now, or do you expect to be, engaged in any other business or employment while working here? Yes No

If yes, please explain:

Are you presently an officer, employee, or employer of another business in our industry or with whom we compete? Yes No

If yes, please explain:

Have you ever been terminated or asked to resign from a job? Yes No

If yes, please explain::

Why do you desire to make a change?

Are you legally eligible to work in the United States? Yes No (Proof of citizenship status/identity required upon hire)

What three things are most important to you in a job?

#1

#2

#3

What three adjectives best describe you?

#1

#2

#3

What type of work do you most enjoy?

Why do you want to work here?

Have you ever been a customer of ours? Yes No - If yes, what services did you receive?

List any special skills, training, experience, certifications, or licenses that may be relevant to this position or our company

List any professional, trade, business, or civic activities or offices held that would relate to working here

List any foreign languages that you fluently speak, read, and/or write that would relate to working here

Have you been convicted of any moving violation(s) in the last 5 years? Yes No - If yes, give date(s) and explanation of each:

Have you ever been disciplined or terminated from any job for an act of violence, harassment, discrimination, ethical breach or theft? Yes No -

If yes, explain the circumstances, employer, and date

Have you ever been a defendant in a civil action for an intentional tort? (e.g. assault, battery, false imprisonment, infliction of emotional distress,
tortuous interference with a business relationship, defamation, invasion of privacy, fraud and misrepresentation, abuse of process and malicious
prosecution or others) Yes No - If yes, provide an explanation of the nature of the intentional tort, the date of the action, the location,
and the disposition or outcome:

Do you currently have any criminal charges pending against you for which you have not been arrested? Yes No -

If yes, describe the details of the charge(s), the date(s) of the offense(s) (month and year), your age at the time of the offense(s), and the current status of the charge(s)

________________________________________________________________________________________________________________________

Are you currently wanted by any law enforcement agency? Yes No -

If yes, by what agency and for what act?

Have you ever been convicted of, received a sentence for, pled nolo contendere (no contest) to, or been placed on probation or fined by any judicial or quasi-judicial body for a crime, other than a minor traffic violation? (Arrest records and juvenile, sealed or expunged records should not be disclosed. Any other criminal record not disclosed by you may be considered falsification of this application, which may result in revocation of your employment offer or termination of your employment. Also, in accordance with any state or federal regulations, you may be required to provide copies of any criminal records. Answering “yes” to this question is not an automatic bar to employment. ) See below for specific instructions related to the state in which you are applying for employment. If the state in which you are applying for employment is not listed, answer this question as worded.
Yes No - If yes*, describe the details of the conviction, the sentence for the conviction, the date of the offense (month and year), your age at the time of the offense, and your rehabilitation since the conviction:

*Nevada Candidates
• List all felony convictions and any misdemeanor convictions that occurred in the past 10 years and that resulted in imprisonment.
• A conviction will not necessarily disqualify an applicant from the position applied for.
*North Dakota Candidates
• List felony convictions only.
*Utah Candidates
• For any convictions, list only felonies.
*Washington State Candidates
• List any convictions or terms of imprisonment within the past 10 years only.

Branch of Service Rank at Discharge (if applicable)

List Duties and Special Training and/or Skills

—————————————————————————————————————————————————————————————————————————

Are you currently subject to a Non-Compete Agreement or Restrictive Covenant that would prohibit you from working at our company in the
position for which you are applying? Yes No -
If yes, provide a copy of the agreement and state the name of the company:

————————————————————————————————————————————————————————————————————

Your Emergency Contact
In Case of an Emergency, I Authorize You to Contact:

Telephone Number Required value.