Date

5/12/2008

First Name:*

Middle Name:*

Last Name:*

Street Address Or Post Office Box:*

City:*

State:*

Zip:*

Home Phone:*

Email Address:*

Social Security #:*

Are you 18 years of age or older?* Yes No

Are you prevented from becoming lawfully employed because of visa or Immigrations status?* Yes No

Have you ever been convicted of a crime, other than a minor traffic offense?* Yes No

If so, please explain:*

Note: A prior conviction will not necessarily bar you from employment; however, the type of conviction and when it occurred will be considered.

Emergency Contact:*

Relationship:*

Address:*

Phone Number:*

Position:*

Date you can start:*

Salary desired:*

Referred by:

Are you able to perform the essential functions of the position for which you are applying?* Yes No

If "No", what accommodation would make it possible for you to perform the essential functions of this position?*

Which shift(s) are you willing to work?* 1st 2nd 3rd

Are you willing to work overtime?* Yes No

Are you willing to work weekends?* Yes No

Are you willing to travel?* Yes No

Are you willing to relocate?* Yes No

Which are you looking for?* Full Time Part Time

Have you applied to this company before?* Yes No

When?*

Where?*

Have you been previously employed by this company?* Yes No

When?*

Where?*

Reason for leaving:*

Grade School:

No. of Years Attended:*

1 2 3 4 5 6 7 8

Did you graduate?* Yes No

High School:

No. of Years Attended:

1 2 3 4

Did you graduate? Yes No

College:

No. of Years Attended:

1 2 3 4 4+

Did you graduate? Yes No

Course of Study:

Apprentice Business or Vocational School:

No. of Years Attended:

1 2 3 4

Did you graduate? Yes No

Course of Study:

Branch of service:

Rank at separation:

Length of service:

Duties:

Identify your 5 previous employers, start with your current or most recent employer.

Current of Most Recent Employer

Employment Dates:*

Company:*

Address:*

City:*

State:*

Zip Code:*

Phone:*

Position:*

Salary:*

Supervisor:*

Reason for Leaving:*

May we contact:* Yes No

Previous Employer

Employment Dates:

Company:

Address:

City:

State:

Zip Code:

Phone:

Position:

Salary:

Supervisor:

Reason for Leaving:

May we contact: Yes No

Previous Employer

Employment Dates:

Company:

Address:

City:

State:

Zip Code:

Phone:

Position:

Salary:

Supervisor:

Reason for Leaving:

May we contact: Yes No

Previous Employer

Employment Dates:

Company:

Address:

City:

State:

Zip Code:

Phone:

Position:

Salary:

Supervisor:

Reason for Leaving:

May we contact: Yes No

Previous Employer

Employment Dates:

Company:

Address:

City:

State:

Zip Code:

Phone:

Position:

Salary:

Supervisor:

Reason for Leaving:

May we contact: Yes No

Previous Employer

Employment Dates:

Company:

Address:

City:

State:

Zip Code:

Phone:

Position:

Salary:

Supervisor:

Reason for Leaving:

May we contact: Yes No

List of names of three persons, not related, you have known at least one year.

Name:*

Address:*

Phone:*

Relationship:*

Years Known:*

Name:*

Address:*

Phone:*

Relationship:*

Years Known:*

Name:*

Address:*

Phone:*

Relationship:*

Years Known:*

By transmitting this application via e-mail, I am certifying that the information (and accompanying resume or information) is true. I agree that the absence of signature is to facilitate the electronic transmission of this application and I further agree that the absence of signature does not in any way negate my ascent to this information and covenants. I also agree and understand that misrepresentations or false or omitted facts may disqualify me from further consideration for employment and may be considered justification for my termination if discovered at a later date.

I authorize investigation of the statements contained herein and the references listed above to give you any and all information such persons, schools, and employers or organizations may have, and release all parties from all liability for any damage that may result from furnishing this information to you. I authorize you to receive any and all information from my entire work and personal history.

I understand that, if hired, my employment is for no definite period and may be terminated at any time, with or without cause, at the discretion of either the company or myself. I understand that I will remain an at will employee and can be terminated at any time without any notice, absent a written contract signed by the President of the Company and myself. If I am employed, it is also understood that the Company, at its sole option and without prior notice, can change wages, benefits, rules, regulations and the conditions of my employment at any time.

I understand an investigation report may be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors, or others with whom the applicant is acquainted. These inquiries may seek information about my character, general reputation, personal characteristics, and mode of living whichever may be applicable. I further understand that I have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I acknowledge that I may be offered employment subject to a medical examination and/or questionnaire, and that such examination and/or questionnaire could nullify my ultimate employment by this employer. I agree to submit to any such medical examination and/or questionnaire.