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All persons, including minorities, disabled persons, and those who are pursuing employment and/or social rehabilitation, are encouraged to complete the following form.  We attempt to ensure that employment decisions are based mostly on past employment, not disability or other illegal disqualifiers.  We are an equal opportunity employer.  All information is required for employment consideration.  Please do not provide information that cannot lawfully be asked of residents of your area.

Please note which of the following employment opportunities you are considering. 

 
Data Entry Shipping Clerk Customer Service Representative
Inventory Control Clerk Software Developer Sales
Delivery Driver Telephone Sales Representative    

About you:

First Name
Last Name
Address
City
State
ZIP Code
Phone Number
E-mail Address
Social Security Number --
Driver's License Number
Birth Date
Do you have a flat-rate,
per-month long distance plan?

Are you willing to work:

Part-time Days Weekends
Full-time Evenings Overtime
    Nights    

 

Other important information

Have you ever been convicted of a felony? What offense? Type of crime:
Have you ever served in the US Military? Branch: Discharge date:

Education

Type Name of school Degree earned Location City & State Dates attended Date graduated
High School Through
College Through
Other Through

Employment

Current/Most Recent

Job Title
Company
Address
City
State
ZIP Code
Phone Number
Supervisor's Name
Salary Per
Dates worked , through ,  
Reason for leaving

Next Most Recent Employment

Job Title
Company
Address
City
State
ZIP Code
Phone Number
Supervisor's Name
Salary Per
Dates worked , through ,
Reason for leaving

Next Most Recent Employment

Job Title
Company
Address
City
State
ZIP Code
Phone Number
Supervisor's Name
Salary Per
Dates worked , through ,
Reason for leaving

Preferred payment method (optional)

If you wish, you may indicate how you would like to be paid. 
No funds will be withdrawn from your accounts.
   
Bank Account
Paypal
Cashier's Check/Money Order
 
Bank
Bank Account Routing Number
Bank Account Number
Type Of Account
Paypal e-mail address

I certify that by submitting this form, the information I have given on this form is true and complete. I understand that any concealment or misrepresentation may be considered cause for denial of employment or termination of employment, regardless of how or when discovered.

I also certify I understand I may be required to work at other than my regular assignment as the needs of the employer require, and my employment is subject to complying with all rules, regulations and conditions established by the employer.

I also certify that if employed, I will give at least 14 days written notice before terminating my employment, unless otherwise specified by contract.

I understand this employment application is not a contract of employment and if hired, I may voluntarily leave employment upon proper notice and that the employer may terminate my employment with or without notice, at any time for any lawful reason. Any oral or written statements made to the contrary are not to be construed as contracts of employment and are not recognized or authorized by the employer.

Immigration Reform and Control Act requires evidence of identity and employment eligibility. I understand that continued employment is contingent upon receipt of appropriate documents.

I understand for the employer and its personnel to make a knowledgeable decision as to my being hired, they must check with my previous employers and affiliations. I consent to and authorize the employer and its personnel to ask any and all of the entities I noted above, in any manner they choose for information concerning me, whether good or bad, and I know that a complete answer is important to my being hired.

I therefore release all parties and persons connected with any request for information from all claims, liability and damages for whatever reason arising out of furnishing and/or otherwise using the information.

 

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