Employment Application Signature Form

I understand that if I am employed and any such information is later found to be false or misleading in any respect I will be dismissed. AUTHORIZATION TO OBTAIN CONSUMER REPORT I CERTIFY THAT I HAVE RECEIVED A WRITTEN NOTIFICATION THAT THE COMPANY MAY OBTAIN A CONSUMER REPORT OR REPORTS ON ME. I AUTHORIZE THIS COMPANY TO OBTAIN SUCH A REPORT OR REPORTS FOR USE IN CONNECTION WITH MY APPLICATION FOR EMPLOYMENT AND FOR OTHER EMPLOYMENT-RELATED REASONS. I UNDERSTAND THAT THE TERM CONSUMER REPORT INCLUDES BUT IS NOT LIMITED TO CREDIT CHECKS CRIMINAL BACKGROUND CHECKS AND DEPARTMENT OF MOTOR VEHICLE REPORTS. Date Signature of Applicant PERSONAL DATA Print Last First Present Address Street and Number City State Zip Previous Social Security No. Middle Telephone No. Have you ever worked for this Company before How long have you lived there Years Months How long did Are you 18 years of age or older Yes No Yes No If Yes please give position dates and Do you have any friends or relatives working here If Yes Name Relationship How would you get to and from work everyday Have you ever pled guilty or no contest to a crime been convicted of a crime or have any criminal charges pending If Yes please give date and details of each Employment App. 11/04 Page 1 NOTE Answering Yes to this question does not constitute an automatic bar to employment. EMPLOYMENT APPLICATION Full time Part time Position Desired Date WE ARE AN EQUAL OPPORTUNITY EMPLOYER APPLICANT S STATEMENT I understand that if I am hired my employment will be for no definite period regardless of the period of payment of my wages. I further one other than the President of the Company has authority to modify this relationship or make any agreement to the contrary. Any such modification or agreement must be in writing. me to submit to an alcohol test and/or medical examination to the extent permitted by law. I authorize the Company to investigate my driving record my credit history and my criminal record. I further understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and other information pertinent to my employment with them* I also authorize the Company to provide truthful information concerning my employment with it to my future prospective employers and I agree to hold it harmless for providing such information* deposit or by a company issued payroll debit card. By signing below I certify that all of the information that I provide on this application and in any interview will be true complete and accurate. Only those crimes which are substantially related to the position you are seeking will be considered* RECORD OF PREVIOUS EMPLOYMENT Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including military service and any period of unemployment. If self-employed give firm name and supply business references. Present or Last Employer Employed Pay From mo/yr Start Address City State Zip Code Your Title or Position Reason for Leaving To mo/yr Final Name and Title of Last Supervisor Telephone Have you ever been terminated or asked to resign from any job Yes No If Yes please explain circumstances Please explain any gaps in your employment history May we contact your current employer Yes No If No please explain Page 2 PREVIOUS EXPERIENCE Skills Please describe any experience you have which you feel would assist you in performing the job for which you are applying.