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 
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 
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Name of Employer: __________________________________________________________________________________
Address: ____________________________________________________________________________________________
Type of Business: _____________________________________________________________________________________
Telephone: (___)______________________ Your Supervisor’s Name:_________________________________________
Your Position and Duties:_______________________________________________________________________________
Dates of Employment: From:_____________________________ To:____________________________________________
Starting Pay:______________________________________ Ending Pay:_________________________________________
May we contact this employer?....................................................................................................................... Yes No
Reason for Leaving:___________________________________________________________________________________
Name of Employer: __________________________________________________________________________________
Address: ____________________________________________________________________________________________
Type of Business: _____________________________________________________________________________________
Telephone: (___)______________________ Your Supervisor’s Name:_________________________________________
Your Position and Duties:_______________________________________________________________________________
Dates of Employment: From:_____________________________ To:____________________________________________
Starting Pay:______________________________________ Ending Pay:_________________________________________
May we contact this employer?....................................................................................................................... Yes No
Reason for Leaving:___________________________________________________________________________________
Name of Employer: __________________________________________________________________________________
Address: ____________________________________________________________________________________________
Type of Business: _____________________________________________________________________________________
Telephone: (___)______________________ Your Supervisor’s Name:_________________________________________
Your Position and Duties:_______________________________________________________________________________
Dates of Employment: From:_____________________________ To:____________________________________________
Starting Pay:______________________________________ Ending Pay:_________________________________________
May we contact this employer?....................................................................................................................... Yes No
Reason for Leaving:___________________________________________________________________________________
Have you ever been terminated or asked to resign your job? If yes, please explain:__________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Please identify and explain all periods of unemployment over the past ten (10) years:
From:____________ To:__________Reason:_______________________________________________________________
From:____________ To:__________Reason:_______________________________________________________________
MILITARY SERVICE
Have you obtained any special skills or abilities as the result of service in the military?............................... Yes No
If so, please describe:__________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
REFERENCES
Please list below three persons not related to you, who have knowledge of work performance within the last three (3) years:
Name:____________________________________ Occupation:________________________________________________
Address:____________________________________________________________________________________________
Telephone: (___)_____________________________ Number of Years Acquainted:_______________________________
Name:____________________________________ Occupation:________________________________________________
Address:_____________________________________________________________________________________________
Telephone: (___)_____________________________ Number of Years Acquainted:_______________________________
Name:____________________________________ Occupation:________________________________________________
Address:_____________________________________________________________________________________________
Telephone: (___)_____________________________ Number of Years Acquainted:_______________________________
ACKOWLEDGEMENT
Please read carefully, initial each paragraph, and sign below.
______ I hereby certify that the information contained in this application is true and correct to the best of my knowledge.
I futher certify that I, the undersigned applicant, have personally completed this application. I understand that any
misrepresentation, falsication or omission of information on this application or any document used to secure
employment shall be grounds for rejection of this application or immediate discharge if I am employed, regardless
of the time elapsed before discovery.
______ I hereby authorize the Company to thoroughly investigate the information on my application, my references, work
record, education and other matters related to my suitability for employment and, futher, authorize the references I
have listed to disclose to the Company 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 or entities from any and all claims, demands or liabilities arising out of or in any way related to such
investigation or disclosures.
______The Company adheres to a policy of AT-WILL employment which means that each employee and the Company
each retain the right to terminate the employment relationship and that the Company retains the right to modify an
employee’s position or compensation at any time, with or without cause or notice. No one other than the President
has the authority to make any binding promise or enter into any agreement inconsistent with Company’s at-will
policy and any such agreement must be in writing and signed by both the employee and the President of the
Company to be effective.
______ As a condition of employment, all individuals offered employment are required to submit to a pre-employment drug test.
Date:_______________________________ Applicant’s Signature:______________________________________________
Rev. 08/07