Present Address

Permanent Address

Employment Desired

____________________________________________________________________________________

 Education History

____________________________________________________________________________________

High School

College

 Trade Business or Correspondence School

 Former Employers

 (List below last four employers, starting with last one first

____________________________________________________________________________________

 Reference

(Give below the names of three persons not related to you, whom you have known at least one year)  

____________________________________________________________________________________

Authorization

"I certify that the facts contained in this application are true and complete to the best of m knowledge and understand that, if employed, falsified statemens on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the reference and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from ultilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employement for Any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a seperate written autorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment verification document form upon hire."