GENERAL INFORMATION

Have you ever used another name?YesNo

Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record?YesNo

If yes to either of the above, please explain:

Have you ever worked for this company before?YesNo

If yes, when:

Do you have friends and/or relatives working for this company?YesNo

If yes, when:

AVAILABILITY

Date you are available to start working:

Do you wish to work:Full TimePart TimeTemporary

If temporary, specify dates available:

From:Till:

Please indicate hours you are available to work each day: example (8am – 5pm)

Wages Desired: $/hrHours Per Week:

If hired, would you have a reliable means of transportation to and from work?YesNo

Can you travel if the position requires it?YesNo

Can you relocate if the position requires it?.YesNo

Are you at least 18 years old?YesNo

Note: If under 18, hire is subject to verification that you are of minimum legal age.

If hired, can you present evidence of your identity and legal right to work in this country?YesNo

Are you able to perform the essential job functions of the job for which you are applying with or without reasonable accommodation?YesNo

Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for qualified applicants/employees to perform essential job functions.

APPLICANT STATEMENT AND AGREEMENT

Please read and initial each paragraph below. If there is anything that you do not understand, please ask.

I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

In the event of my employment with the Company, I understand that I am required to comply with all rules and regulations of the Company and may be required to drug test at any time.

If hired, I understand and agree that my employment with the Company is at-will, and that neither I, nor the Company is required to continue the employment relationship for any specific term. I further understand that the Company or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.

I understand that safety of employees is extremely important to the Company and that the Company is committed to ensuring a safe working environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site supervisor. I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health.

I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I9 Form in this regard.

I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed and the remainder of this Agreement shall be enforceable.