Note: All applicants who are offered employment are required to complete a livescan background investigation at their expense. Employment will only be finalized once the background check clears. Employees will be reimbursed for the full cost of the livescan upon completion of 30 days of employment with the company. Reimbursement will not be given if you do not meet the 30-day requirement.

16. High School Education: Name and Location *

17. College Education: Name and Location

18. College Education: Name and Location

19. List any professional License/Certifications you have:

20. List any special skills that you feel qualify you for the job in which you are applying:

21. Please describe your computer skills: *

22. Is there any additional information relative to change of name, use of an assumed name, or nickname necessary to enable a check on your work and educational records?

Please list the names of your present or previous employers in choronological order with the most present employer listed first. You may include any verifiable work performed on a volunteer basis or internships.

YOUR FAILURE TO COMPLETELY RESPOND TO EACH INQUIRY MAY DISQUALIFY YOU FOR FUTURE CONSIDERATION OF EMPLOYMENT.

23. Employer:

23a. Street Address:

23g. Number of Weekly Hours:

23h. Duties:

23i. Reason for leaving:

23j. Supervisor's Name:

23l. If no, why not?

24. Employer:

24a. Street Address:

24e. Phone Number:

24g. Number of Weekly Hours:

24h. Duties:

24i. Reason for Leaving:

24j. Supervisor's Name:

24l. If no, why not?

25. Employer:

25a. Street Address:

25g. Number of Weekly Hours:

25h. Duties:

25i. Reason for Leaving:

25j. Supervisor's Name:

25l. If no, why not?

33. Please explain fully any gaps in your employment history in excess of one month.

37. If you answered Yes to any of the above three questions, please explain the circumstances of each occasion.

E. APPLICANT CERTIFICATION:

I certify that all the information on this application, my resume, or any supporting documents I may present during this interview is, and will be, complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment, or if employed, disciplinary action, up to and including immediate dismissal.
I understand that neither this application nor any communication by a management representative is intended to create nor does it create a contract of employment, offer, or promise of employment for a definite term. I understand that if hired by the company, employment is on an at-will basis in accordance with state law. This means the company is free to terminate my employment at any time, with or without cause or advance notice, in accordance with state law, and acceptance of employment is not a contract of employment at any time for any reason. This at-will provision may be modified or waived only in a written agreement by an authorized representative of the company and myself.
I agree to conform to the rules and regulations of the company, and I understand that the company has complete discretion to modify such rules and regulations at any time, except that it will not modify its policy of employment at-will.
I authorize the company or its representative to confirm all statements contained in this application and/or resume as it relates to the position for which I am applying and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation.
I authorize and consent to, without reservation, any party or agency contracted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the company or its authorized representative pursuant to this authorization from any liability claims, charges, or causes of action, which I may have as the result of the delivery or disclosure of the above requested information. I hereby release from liability the company and its representatives for seeking such information and all other persons, or organizations furnishing such information.
If hired by this company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the U.S. by this company. I also understand this company employs only individuals who are legally eligible to work in the U.S.
I affirm that I own or have ample access to a computer, have an email account, have general knowledge of operation and care of a computer, computer hardware/software, can implement some basic troubleshooting techniques, and have a basic understanding of how to use the internet.
I affirm that I have a valid driver's license without any restrictions, and reliable transportation (with appropriate and valid insurance) to get to and from my designated work location.
THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

44. Print full name: *