Application for Employment Equal access to programs, services and employment opportunities is granted to all persons without regard to sex (including pregnancy) race, color, religion, national origin, citizenship, age, disability, genetic information, or any other basis protected by federal, state, and/or local law. In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of accommodation include making a change to the application process; providing written materials in an alternate format such as braille, large print or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions. Name* First Middle Last Applicant ID#Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary phone*Secondary phoneEmail* Position(s) applied for*Referral Sourcese.g., Walk-in, Job Posting, Company Website, etc.Employment EligibilityIf necessary, what is the best time to call you? : HH MM AM PM Preferred Phone Number Primary Phone Secondary Phone May we contact you at work?YesNoWork phone number*Best time to call* : HH MM AM PM If you are under 18 and it is required, can you furnish a work permit?*N/AYesNoPlease explain*Have you submitted an application here before?YesNoWhat position(s)*Date* Date Format: MM slash DD slash YYYY Have you ever been employed here before?YesNoFrom* Date Format: MM slash DD slash YYYY To* Date Format: MM slash DD slash YYYY Are you requesting reemployment following an extended military leave of absence from this company?*YesNoIf "Yes", additional information may be requestedAre you lawfully authorized to work in the United States*YesNoDate available to start work* Date Format: MM slash DD slash YYYY Desired salary range or hourly rate*Per*YearHourType of Employment Desired* Full-Time Part-Time Educational Co-Op Seasonal Temporary Will you relocate if the job requires it?*YesNoWill you travel if the job requires it?*YesNoIf they have been explained to you, are you able to meet the attendance requirements of the position?*N/AYesNoWill you work overtime if required?*YesNoIf "no", please explain*Are you able to preform the "essential functions" of the job for which you are applying (with or without reasonable accomodation)*YesNoNeed more information about the jobs "essential functions"This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law. Drivers License NumberRequired if driving may be required in the position for which you are applying:State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificHave you ever been bonded?*YesNoHave you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?*YesNoIf "Yes", please explain*Employment HistoryStarting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis. EmployerTelephone #Street AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStarting Job Title / Final Job TitleDates Employed Date Format: MM slash DD slash YYYY to: Date Format: MM slash DD slash YYYY Immediate supervisor and title (for most recent position held)Why did you leave?Summarize the type of work and job responsibilitesWhat did you like most about the position?What did you like least about the position?Add Another PositionRemove PositionEmployment History(continued)Explain any gaps in your employment, other than those due to personal illness, injury, or disability.If not addressed on previous page, have you ever been fired or asked to resign from a job?* Yes No If "yes", please explain*Skills and QualificationsSummarize any special training, skills, languages, licenses, and/or other certificates that may assist you in performing the position for which you are applying Computer Skills (Include software titles and level of experience, such as basic, intermediate, or advanced.) Word Processing Software*Level* Spreadsheet Software*Level* Presentation Software*Level* Email Software*Level* Internet Software*Level* Other Software*Level* Other Software*Level* Other Software*Level* Educational BackgroundStarting with your most recent school attended, please provide the following information:School (Include City and State)Years attendedCompleted (eg: Degree, GED, Diploma)GPA / RankMajor / Minor ReferencesList names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you. NameTitleRelationship to youTelephoneEmail# of years known Related InformationWhen answering these questions, please exclude any information that would reveal sex (including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or other similarly protected status.To what job-related organizations (professional, trade, etc) do you belong?List special accomplishments, publications, awards, etc.List any relevant volunteer work.Is there any other job-related information you want us to know about you?Applicant StatementConsent* I certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct.I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resumé, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law. I understand that this application remains current for 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are written and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete and I-9 Form in this regard. I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer's affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer. This company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an application from consideration for employment on the basis of his or her race, religion, color, sex (including pregnancy, sexual orientation, and gender identity), age, national origin, disability, marital status, height, weight, genetic information, or any other protected status under applicable federal, state, or local law. Mandatory Employer Disclosures Notice to Maryland applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100. Notice to Massachusetts applicants: It is unlaWful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Notice to Rhode Island applicants: This company complies with Rhode Island law prohibiting smoking in enclosed areas within places of employment. Notice to North Dakota applicants: This company complies with North Dakota law prohibiting smoking within 20 feet of entrance and inside places of employment. Notice to Indiana applicants: This company complies with Indiana law prohibiting smoking in enclosed areas within places of employment. Notice to Illinois applicants: Please be advised pursuant to Illinois law, applicants are not obligated to disclose expunged juvenile records of adjudication, arrest, or conviction. I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.Digital Signature*DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. First PhoneThis field is for validation purposes and should be left unchanged.