Employee Application Step 1 of 6 16% Name(Required) First Last SSN(Required)Address(Required) 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Phone(Required)Email(Required) Referral Source(Required) Walk-In Employee Advertisement Company's Website Other Internet School Job Fair Staffing Agency Government Employment Agency Other Referral Name If necessary, best time to call you at home is:(Required) Hours : Minutes AM PM AM/PM Have you submitted an application here before?(Required) Yes No May we contact you at work?(Required) Yes No If Yes, date and position(s)(Required) MM slash DD slash YYYY Position(s)(Required)If yes, what is your work number?(Required)Have you ever been employed here before?(Required) Yes No Best time to call at work? Hours : Minutes AM PM AM/PM if yes, Start Date(Required) MM slash DD slash YYYY End Date(Required) MM slash DD slash YYYY If no, Please Explain:Section BreakAre you legally eligible for employment in this country(Required) Yes No Will you work overtime if required?(Required) Yes No Date available for work(Required) MM slash DD slash YYYY Please explain(Required)Desired Salary Range(Required)Ex.) $7.25/hrDriver's license(Required) ID number required if driving may be required in the job for which you are applyingState(Required)Type of employment desired(Required) Full Time Part Time Seasonal Temporary Will you relocate if the job requires it?(Required) Yes No Will you travel if job requires it?(Required) Yes No Have you ever been bonded?(Required) Yes No Answering "yes to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be take into account.Have you ever pled "guilty" or "no contest" to or been convicted of a crime?(Required) Yes No Please provide date(s) and detail(s)(Required) Employment History Employer Start Date End Date Actions Edit Delete There are no Jobs. Add Job Maximum number of jobs reached. Employment History ContinuedExplain any gaps in your employment, other than those due to personal illness or injury or disabilities:If not addressed on previous page, have you ever been fired or asked to resign from a job?(Required) Yes No Please explain(Required)Skills & QualificationsSummarize any special training, skills, licenses and/or certificate that may assist you in performing the position for which you are applyingComputer Skills Word Processing Spreadsheets Presentation E-mail Internet Other Include any software titles and years of experience Educational BackgroundStarting with your most recent school attended, provide the following informationSchool(Required)Did you complete?(Required) Yes No Level of accomplishment(Required)SchoolDid you complete? Yes No Level of accomplishmentSchoolDid you complete? Yes No Level of accomplishmentSchoolDid you complete? Yes No Level of accomplishmentReferencesList name and telephone number of three business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are NOT related to you.Name(Required)Length of relationship(Required)Telephone(Required)Relationship(Required)Name(Required)Length of relationship(Required)Telephone(Required)Relationship(Required)Name(Required)Length of relationship(Required)Telephone(Required)Relationship(Required)Related InformationTo what job-related organizations (professional, trade, etc.) do you belong? *Excluding memberships that would reveal race, color, religion, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similar protected status.*OrganizationOffices HeldOrganizationOffices HeldOrganizationOffices HeldList Special Accomplishments, publication awards, etc.*Excluding memberships that would reveal race, color, religion, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similar protected status.*In your current or prior job, have you ever written instructions or directions to be followed by employees or customers? Yes No Please explain:Is there any other job-related information you want us to know about you? Consent(Required) I certify that I have read, fully understand and accept all terms of the foregoing Applicant StatementI certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment for employment on any basis prohibited by applicable local, state or federal law. In understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. if I'm hired, I understand that I'm free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make assurance to the contrary and that no implied oral or written agreements contrary to the foregoing expressed language and valid unless that are in writing and signed by the employer's president. I understand that during the first ninety (90) days of my employment, I am on probation. This is considered an initial trial period during which time I can make a trial evaluation of my skills on the job to ascertain my qualifications for further employment with the company. At any time during the 90-day period, either the company, or the employee is free to terminate the probationary employment without prejudice. I also understand that if I am hired, I wil be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.Signature of Applicant(Required) First Last Date(Required) MM slash DD slash YYYY Δ