Employment Form 1. Personal Information Date (required) Social Security Number (required) First Name (required) Middle Name Last Name (required) Other Names Phone Number (required) Email (required) Present Street (required) Present City (required) Present State (required) Present ZIP (required) Permanent Street Permanent City Permanent State Permanent ZIP Are you of legal age to work? (required) —Please choose an option—YesNo Can you, upon employment, submit verification of your legal right to work in the U.S.? (required) —Please choose an option—YesNo 2. Position Applying For Position (required) Earliest Possible Start Date (required) Are you currently employed? (required) —Please choose an option—YesNo What type of work are you seeking? (required) —Please choose an option—Full-TimePart-Time Desired Shift Have you ever applied to this company before? (required) —Please choose an option—YesNo Where? When? Desired Salary $/Hour $/Year How did you hear about this job opening? (required) —Please choose an option—Employment Advertisement - NewspaperEmployment Advertisement - InternetCommunity Job PostingRecruitment ServiceEmployment AgencyFacility Staff Member 3. Education Grammar School / Name & Location Grammar School / Number of Years Attended Grammar School / Degree Achieved Grammar School / Subjects Studied High School / Name & Location High School / Number of Years Attended High School / Degree Achieved High School / Subjects Studied College / Name & Location College / Number of Years Attended College / Degree Achieved College / Subjects Studied Graduate School / Name & Location Graduate School / Number of Years Attended Graduate School / Degree Achieved Graduate School / Subjects Studied Trade, Business, or Correspondence School / Name & Location Trade, Business, or Correspondence School / Number of Years Attended Trade, Business, or Correspondence School / Degree Achieved Trade, Business, or Correspondence School / Subjects Studied 4. General Subjects of Special Study, Interest or Research Work Special Skills Activities (Civic, Athletic, Etc.)* US Military or Naval Service Rank Present membership in National Guard or Reserves? —Please choose an option—YesNo *Exclude organizations, the name of which indicates race, creed, religion, sex, age, marital status, color, sexual orientation or national origin of its members. 5. Former Employers Employer 1 Name (required) Address (required) Phone (required) Position (required) Start Date (required) End Date (required) Reason for Leaving Supervisor (required) May We Contact (required) —Please choose an option—YesNo Employer 2 Name (required) Address (required) Phone (required) Position (required) Start Date (required) End Date (required) Reason for Leaving Supervisor (required) May We Contact (required) —Please choose an option—YesNo Employer 3 Name (required) Address (required) Phone (required) Position (required) Start Date (required) End Date (required) Reason for Leaving Supervisor (required) May We Contact (required) —Please choose an option—YesNo Which of these jobs did you like best? What did you like most about this job? 6. References Reference A Name (required) Address (required) Phone Number (required) Business (required) Years Acquainted (required) Reference B Name (required) Address (required) Phone Number (required) Business (required) Years Acquainted (required) Reference C Name (required) Address (required) Phone Number (required) Business (required) Years Acquainted (required) Are you able to perform the essential job functions of the position you are applying for with or without accommodation? (required) —Please choose an option—YesNo A copy of the job description is available from the facility administrator. If you can perform the job function with an accommodation, please describe how you would perform the functions and with what accommodations. 7. Read carefully and sign below if you agree to these terms of employment I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations. I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing. Date (required) Initials (required) 8. Authorization and Waiver I authorize and request my former employers, references, educational institutions, and any credit agencies or reporting services which have information about me, to give this potential employer and its subsidiaries any and all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and I release such former employers, references, educational institutions, and credit agencies or reporting services from any liability or claim relating to such release of information and opinions. I also authorize and request federal, state and local government agencies to release to this potential employer and its subsidiaries any information requested concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original. Date (required) Name (required) Address (required) Phone Number (required) Email (required) Social Security Number (required) Signature (required)