Are you authorized to work in the United States?

What method of transportation will you use to come to work?

Position (s) applied for:

Attach a copy of your resume

Qualifications

Do you have any special training, skills, qualifications or other experiences that relate to the position(s) applied for?

Work Performed

Work Performed

Work Performed

Work Performed

Reference #1

Reference #2

Reference #3

Have you had any experience in the Armed Forces of the United States or in a State National Guard?

Are you in the reserves?

Special/technical training

Have you been convicted of a crime?

Do you have a valid driver's license?

List professional trade, business or civic activities and offices held excluding groups the name or character of which indicate race, color, religion, sex, national origin, handicap, marital or veteran status, height, weight or age

State any additional information that you feel may be helpful to us in considering your application.

Name, address, and telephone number of the person to be notified in the event of accident or emergency

AUTHORIZATION AND UNDERSTANDING:

Upon the signing of this application, I represent that all of the information now or hereafter given by me in support of my application is true and complete. I authorize you to verify any of the information concerning my background, including but not limited to, my employment, driving record, education, criminal history, or medical history (post-offer only), with the appropriate individuals, companies, institutions or agencies, and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I also authorize you to release any information requested by any of my prospective or subsequent employers without any obligation to give me written notice of such disclosure. I hereby release you and them from any liability whatsoever as a result of any such inquiries and disclosures and this release from liability does not waive or prohibit an individual from filing a charge of discrimination under the laws enforced by the EEOC. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment. I agree that either party may terminate the employment relationship, with or without cause, at any time, and I further agree that this arrangement may only be altered in writing directed to me personally and signed by the president of the Company. I agree that I shall be bound by the other rules, policies, regulations and terms and conditions of employment of the Company as they are from time to time changed, and no additional obligations can be imposed on the Company except those which have been acknowledged in writing, by the president or his designated representatives. I agree that any action or suit against the Company, its agents or employees, arising out of my employment or termination of employment, including, but not limited to, claims arising under State and Federal law, but not Federal civil rights statutes containing a separate limitations period, must be brought within 180 days of the event giving rise to the claims or be forever barred unless the applicable statute of limitations period is shorter than 180 days in which case I will continue to be bound by that shorter limitations period. I waive any limitation periods to the contrary. I further agree that if I should bring any non-statutory action or claim arising out of my employment against the Company, in which the Company prevails, I will pay to the Company any and all such costs incurred by the Company in defense of said claims or actions, including attorney fees. I further agree that my employment is conditional until such time as the results of my post-offer physical (if such physical is required) are known.