Do you possess any other background, training, skills or knowledge that qualify you for the position applied for?

Yes

If yes, please specify:

U.S. military service:

Rank?

Are you 18 years of age or older?

Yes

(Note: persons under 18 must verify they are a minimal legal age to be hired.)

If the company hires you, will you be able to document your legal right to live and be employed in the U.S.?

Yes

Have you been convicted at any time of a felony or serious criminal misdemeanor?

Yes

If yes, specify the crime(s), the date and location of the conviction and the current status of the case:

(Note: an applicant will not be turned down for employment solely because he/she has been convicted of a crime. The particular crime, the date of conviction, the circumstances of the crime and the relation of the nature of the crime to the position being applied for can be considered by the company in making the decision).

If you are applying for a professional position:

Do you have a license or certificate for the position desired?

Yes

License or certificate name:

License or certificate number:

State of issuance:

Date of issuance:

Has the license or certificate been suspended or revoked at any time?

Yes

History of Employment

Employment History				Actions
Employer		From
Position		To
Address
Phone		Supervisor
Salary		Supervisor's Email

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Additional References

Please supply three people not related to you who can supply first-hand information of your work skills and performance within the past four years.

Attestations

"I have read and understand the job description for the position I am applying for.":

Yes

"I am able to carry out the essential aspects of the position I am applying for.":

Yes

"I acknowledge and attest that I have completed this application for employment personally and that all the answers in this application are complete and accurate. I also acknowledge and attest that I have not omitted or failed to disclose any data that may reduce my prospects for employment with this company. I further acknowledge, attest and agree that any omission or failure to disclose relevant information shall cause the company to reject the application or, if I am hired, immediately terminate my employment, no matter how much time has passed before the company learns such information.":

Yes

Note: This company complies with the federal Americans with Disabilities Act, Title VII of the Civil Rights Act of 1964 and other applicable law and will strive to implement measures needed to reasonably accommodate qualified applicants and employees to handle essential functions of a job. Hiring may be conditioned on passing a medical examination and/or tests of skills and dexterity.

Type of School	Name and Location of Institution	Years Attended	Did you Graduate?	Degree or Diploma	Subject Studied
High School
College or University
Trade, Vocational or Other School

Name	Phone	Email	Business	Occupation	Years Known

Employment Application

Contact Data

Employment Applying For

Education

General

If you are applying for a professional position:

History of Employment

Additional References

Attestations

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