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Date

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Last Name First Middle

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Present Address City State Zip

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Permanent Address (if different from above) City State Zip

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Day Time Phone Message Number

Position(s) Desired:_____________________________________ Salary Requested:______________________

Yes No

Can you, after employment, provide verification of your legal right to work in the United States?

Are you at least 18 years of age?

Date available for employment? __ __-__ __-__ __

Have you ever worked for us? If so, when: __ __-__ __-__ __

Are you applying for: Regular Full-time Work

Regular Part-time Work

Temporary Work

(e.g., summer or holiday) Specify:__________________

Specify any hours or days you cannot or will not work:____________________________________________

Are you willing to work overtime if needed?

Are you willing and able to travel as necessary?

How were you referred to us? Employee Referral Advertisement Employment Agency

College/School Friend/Relative Other Specify Source: ___________________

List any friends and/or relatives working at (COMPANY NAME), and their relationship to you:

Name:______________________ Office Location:___________________ Relationship:___________________

Name:______________________ Office Location:___________________ Relationship: ___________________

Additional academic achievements, training, skills or extracurricular activities relating to the position(s) for which you are applying:

EMPLOYMENT HISTORY: (Start with most recent position. Use additional sheet if necessary. Do not omit any employers.)

May we contact your current employer at this time? Yes No

If you are currently employed under a written contract with any company, and that contract restricts you in any way in working for a competitor, please specify the restrictions:_____________________________________________

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List all registrations, certifications, or licenses related to the work for which you are applying.

Have you obtained any special skills or abilities as the result of service in the military Yes No

If so, describe: ________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________

In the last 5 years, have you ever been convicted of a felony, or a misdemeanor that resulted in imprisonment?

Yes No

If yes, describe nature of the crime(s), when and where convicted and disposition of the case: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Provide the names of three persons not related to you who you have known at least one year. References should be acquainted with your employment background.

The essential requirements of the job for which you are applying are specified on the attached job description. Some positions may require that the applicant pass a job related physical examination.

I hereby certify that all information contained in this application is true and correct to the best of my knowledge. I further certify that I have not knowingly withheld any information that may adversely affect my chances for employment. I understand that any error or omission of information may result in denial of employment or termination at any time. I authorize all my current and former employers and their employees, past or present, to give (COMPANY NAME) any and all information concerning my employment history and any pertinent information they may have, personal or otherwise. I also authorize that all my former schools may give (COMPANY NAME) any or all information concerning my education. I also authorize all the references that I have provided to give any information to (COMPANY NAME) they consider relevant. I waive all privacy interests in such information.

I further release all the sources referenced above (and all their employees, officers, directors and agents) and (COMPANY NAME) (and its employees, officers, directors and agents) of all claims and liability for any damage resulting from their furnishing any information, whether I agree or disagree with the content of the disclosed information. Thus, I understand that if any one of the above sources discloses information which I believe to be erroneous, I cannot bring any legal action against that source or (COMPANY NAME) regarding the disclosure of the information. In this regard, I waive any and all benefits associated with California Civil Code Sections 1542, which provides: "General Release/Claims Extinguished. A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor."

I authorize (COMPANY NAME) (or its designated investigator) to obtain any criminal conviction records about me from any federal, state or local law enforcement agency or court. I further release (COMPANY NAME) (and its employees, officers, directors and agents) and any court or law enforcement agency from any and all liability for any damages resulting from furnishing of any criminal conviction information, whether I agree or disagree with the contents of the information.

I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application. I further agree, in the event that I am hired by (COMPANY NAME), that all disputes that cannot be resolved by informal internal resolution which might arise out of my employment with (COMPANY NAME), whether during or after that employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. This application contains the entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution, either oral or written.

I understand that (COMPANY NAME) is an at-will employer and that my employment can be terminated with or without cause, at any time and for any reason, or no reason, at the option of either the Company or myself. I understand that no one, other than the Chairman of the Board/CEO of (COMPANY NAME) has any authority to enter into an agreement for employment for a specified period of time, or to make any agreement contrary to the foregoing. Any agreement entered into by the President can only be made in writing signed by him/her and the employee.

I understand that the issuance of this application does not indicate that there any positions open.

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Applicant's Signature Date