Some packets may have an attached AFFIRMATIVE ACTION QUESTIONNAIRE. This information is being gathered of affirmative action under Section 503 0f the Rehabilitation Act of 1973. The information requested is voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete the questionnaire. NAME: Social Security Number Home phone Work Phone Current Address Prior Address APPLICANT NOTE This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, age, creed, national origin or the presence of disabilities. A felony conviction will not necessarily bar an applicant form employment. Affirmative action hiring may be requested by qualified applicants. Additional testing of job-related skills for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you are required to submit to a medical review. Depending on the company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company. Availablity For which position are you applying? What date can you start? What category would you prefer? Full-timePart-timeTemporaryLabor pool For which schedules are you available? WeekdaysWeekendsEveningsNightsOvertimeShiftOther Education Please choose highest grade completed 7891011121314151616+ Please fill table below(if applicable) Security Have you used other names or Social Security Numbers other than those on this page? If so, please list below. Have you been convicted of a felony and/or served time in the past 7 years? If so, please describe below. (In accordance with company policy this information will be reviewed for job relatedness and time since last conviction). Job Related Skills List languages in which you are fluent If the job requries, do you have the apropriate valid driver's license? Have you had any moving violations? Please provide information below. Please list any other skills, licenses or certificates that may be job related or that you feel would be a value of this job or company. Please write below Have you been given a job description or had the requirements explained to you? yesno Do you understand these requirements? yesno Can you perform the requirements of this job with or without reasonable accommodation? yesno Employment References Your application will not be considered unless every question in this section is answered. Since we will make evrey effort to contact previous employers the correct telephone numbers of past emploeyers are critical. Most recent employer Are you currently working for this employer? YesNo If yes, may we contact? YesNo Dates employed Job Title Supervisor Name Duties Salary Reason for leaving Second most recent employer Dates employed Job Title Supervisor Name Duties Salary Reason for leaving References Please include only individuals familiar with your work ability. Do not include relatives. Leave any comments you have below I certify that I have read and understand the applicant note on the page of this form and that the answers given by me to the foregoing questions and statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus to verify any of this information including, but not limited to, criminal history, and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.