Application For EmploymentStep 1 of 520%Position(s) Applied forDate of Application Date Format: MM slash DD slash YYYY Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Main Phone NumberAlternate Phone NumberEmail EMPLOYMENT EXPERIENCEPlease list the names of your present or previous employers in chronological order with present or most recent employer listed first. Be sure to account for all periods of time. If self-employed, give firm name and supply business references. Add additional page if necessary.Name of EmployerSupervisorMay we contact? Yes NoStreet AddressPhoneDates Employed From (Month/Year)Dates Employed To (Month/Year)Job Title and DutiesReason for LeavingName of EmployerSupervisorMay we contact? Yes NoStreet AddressPhoneDates Employed From (Month/Year)Dates Employed To (Month/Year)Job Title and DutiesReason for LeavingName of EmployerSupervisorMay we contact? Yes NoStreet AddressPhoneDates Employed From (Month/Year)Dates Employed To (Month/Year)Job Title and DutiesReason for LeavingHave you ever been involuntarily terminated or asked to resign from any job? Yes NoIf yes, please explainPlease explain any gaps in your employment history:Please list any other experience, job related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment. EDUCATIONHighest level of educationHigh SchoolCollege/UniversityGraduate/Professional SchoolTrade SchoolOtherREFERENCESPlease list three professional references of individuals who are not related to you.Name and TitleRelationshipPhone Number or EmailName and TitleRelationshipPhone Number or EmailName and TitleRelationshipPhone Number or EmailPERSONAL REFERENCESPlease list three people who know you well.Name and TitleRelationship and Years AcquaintedPhone Number or EmailName and TitleRelationship and Years AcquaintedPhone Number or EmailName and TitleRelationship and Years AcquaintedPhone Number or Email GENERAL INFORMATIONHave you ever used another name? Yes NoIs 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? Yes NoIf yes to either of the above, please explainHave you ever worked for this company before? Yes NoIf yes, please give dates and positionDo you have friends and/or relatives working for this company? Yes NoIf yes, name(s) and relationship(s):On what date are you available to begin work?Days/Hours available to work:Are you available to work?Full-timePart-timeShift WorkTemporaryMinimum salary required:Per Hour $If hired, would you have a reliable means of transportation to and from work?YesNoCan you travel if the position requires it?YesNoCan you relocate if the position requires it?YesNoAre you at least 18 years old?Note: If under 18, hire is subject to verification that you are of minimum legal age.YesNoIf hired, can you present evidence of your identity and legal right to work in this country?YesNoAre you able to perform the essential job functions of the job for which you are applying with or without reasonable accommodation?Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for qualified applicants/employees to perform essential job functions.YesNo APPLICANT STATEMENT AND AGREEMENTPlease read and initial each paragraph below. If there is anything that you do not understand, please ask.Consent* I agreeI 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.Consent* I agreeIn the event of my employment with the Company, I understand that I am required to comply with all rules and regulations of the Company.Consent* I agreeIf 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.Consent* I agreeI 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.Consent* I agreeI 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.Consent* I agreeI 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 I-9 Form in this regard.Consent* I agreeI 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.BY CLICKING THIS BOX ATTESTS TO THE FACT THAT I HAVE READ, UNDERSTAND, AND AGREE TO ALL OF THE ABOVE TERMS.* I agree to the policy.