Employment Application

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended to evaluate suitability for employment. It is the policy of the company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, national origin, citizenship, disability, veteran status, or any other status protected under local, state or federal law. It is also the policy of the company to have the option of conducting pre-employment screening before a job offer is made. If a job offer is made, employment may be contingent upon the successful completion of a pre-employment drug screening and/or medical examination. This application will remain active for 3 years.

Personal Information

First Name *:	Middle Name :	Last Name *:
Home Phone :	Work Phone :	Cell Phone *:
Email Address *:

Addresses

Street :

City :

State :

Zip Code :

Since (Mo/Yr) :

To (Mo/Yr):

Education

	School Attended:	City:	State:	Diploma:	Degree/Cert.:	Area of Study
High School:				No Yes	GED
Undergrad School:				No Yes
Grad School:				No Yes
Other School:				No Yes

Job-related Skills

	Please answer the following questions if the position you are applying for requires driving a motor vehicle:
1.	Do you have a valid driver's license?	No Yes
	If yes, Driver's License Number: Date of Issue:
2.	Have you been convicted of or pled guilty to any traffic-related offense within the past five years?	No Yes
	If yes, please explain...
3.	Have you had your driver's license suspended or revoked or had your driving privileges modified by a court of law?	No Yes
	If yes, please explain...
4.	Please list all states from which you hold or held a driver's license:
	Please use this space to list any special skills you may have that relate to the position applied for:
	Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted, name of organization, and any other relevant information.

References

	Reference (1)	Reference (2)
Name :
Address :
Telephone :
Relationship :
Years Acquainted :

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