An Equal Opportunity Employer
We do not discriminate on the bases of race, color, religion, national origin, gender, sexual orientation, age, or disability. It is our intention that all qualiﬁed applicants will be given equal opportunity and that selections decisions be based on job-related factors.
Each question is to he answered fully and accurately. No action can be taken on the application until all questions have been answered.
Position Applied for
Possible Start Date
Present Street Address
Are you 18 years of age, or older?
(If hired you may he remind to submit proof of age)
If hired, can you submit proof you are eligible to work in the US?
Are you a citizen of the United States?
If no, are you authorized to work in the U.S.?
Have you ever worked for this company?
If yes, when and where?
Have you ever been convicted of a felony?
If yes, explain:
("Yes" does not automatically disqualify you from employment. because the nature of the offense, date, and position for which you are applying will also he considered)
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or
interview may result in my release. I authorize and agree to cooperate in a thorough investigation of all statements
made herein and other matters relating to my background and qualifications. I understand that any investigation
conducted may include a request for employment and educational background, credit reports, consumer reports,
driving record, and criminal history. I authorize any person, school, current, and former employer, consumer
reporting agency, and any other organizations or agency to provide information relevant to such investigation and I
hereby release all persons and corporations requesting or supplying information pursuant to such investigation from
all liability or responsibility to me for doing so. I understand that I have the right to make a written request within a
reasonable period of time for complete disclosure of the nature and scope of any investigation. I further authorize any
physician or hospital to release any information which may be necessary to determine my ability to perform the job
for which I am being considered or any future job in the event that I am hired. I understand that I may be required to
successfully pass a drug screening examination. I hereby consent to a pre- and/or post -employment drug screen as a
condition of being hired or of my continued employment, if required.
I have read, understand, and by my signature consent to these statements.