APPLICATION FOR EMPLOYMENT

Notice to All Applicants: Our Company is an Equal Opportunity Employer and does not discriminate due to race, sex, religion, national origin, age, handicap or status as a disabled veteran or veteran of the Vietnam era.

__________________________________________________________________________

Date:  ___________                                         

Position Sought (Be specific): _________________________________________________

Name (Last, First, MI, Name used): ___________________________________________

Soc. Security No.  __________________    l8 or over? ____  

Eligible to work in US? ____

Where can we contact you:? 

Address________________________________________

Phone__________     Best times? _________    

How were you referred to us? ________

EDUCATION/TRAINING

Name/location of school	Courses studied	GPA	Graduated?

PHYSICAL/MENTAL/ATTENDANCE QUALIFICATIONS

Can you meet all requirements of the job applied for (including attendance requirements), with or without reasonable accommodation? ____  If no, please describe requirements which you cannot meet: ______________________________________________________________

How often were you absent from work during the past year? _________________  

How often were you late for work? ___________________

EMPLOYMENT HISTORY (List all jobs held within the past 10 years, with most recent job listed first.  Use extra sheets if necessary)

Company Name	Positions Held	Last Supervisor	Final Payrate	Reason for Leaving
Address/Phone	Experience       Acquired:	Machines Operated:	Software Used:	If laid off, will you accept recall?

Company Name	Positions Held	Last Supervisor	Final Payrate	Reason for Leaving
Address/Phone	Experience       Acquired:	Machines Operated:	Software Used:	If laid off, will you accept recall?

Company Name	Positions Held	Last Supervisor	Final Payrate	Reason for Leaving
Address/Phone	Experience       Acquired:	Machines Operated:	Software Used:	If laid off, will you accept recall?

Explanation for gaps: _______________________________________________________________________

Other training or experience: ____________________________________________________________________

Are you claiming Veterans preference?  _________ As disabled vet? ___(If so, we will need proof of your service-connected disability).  Please list date of discharge, type of discharge, and highest rank  

I certify that the above information is correct and truthful, and that falsification of this application is grounds for rejection of the application or immediate discharge if I have been hired. I authorize you to contact any prior employers, and release them and you from any liability arising from disclosure of information concerning my past employment history. I understand that, as a condition of employment, I may be asked to pass a medical exam and to take a drug and or alcohlol test and that, if employed, I will be employed "at will".

Applicant Signature _____________________