PERSONAL INFORMATION NAME: PRESENT ADDRESS: CITY: STATE: ZIP: PHONE #: EMAIL: REFERRED BY: EMPLOYMENT DESIRED POSITION: DATE YOU CAN START: SALARY DESIRED: ARE YOU EMPLOYED NOW? IF SO, MAY WE CONTACT YOUR PRESENT EMPLOYER? Yes No EVER APPLIED TO THIS COMPANY BEFORE? Yes No WHEN AND WHAT POSITION? EMPLOYMENT HISTORY (LIST BELOW LAST 5 YEARS OF EMPLOYMENT WITH LAST ONE FIRST) EMPLOYER 1 FROM TO NAME & ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING EMPLOYER 2 FROM TO NAME & ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING EMPLOYER 3 FROM TO NAME & ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING REFERENCES (PERSONS NOT RELATED TO YOU KNOWN FOR AT LEAST 1 YEAR) REFERENCE 1 NAME ADDRESS BUSINESS YEARS KNOWN REFERENCE 2 NAME ADDRESS BUSINESS YEARS KNOWN REFERENCE 3 NAME ADDRESS BUSINESS YEARS KNOWN EDUCATION HISTORY HIGH SCHOOL NAME & LOCATION OF SCHOOL YEARS ATTENDED DID YOU GRADUATE? Yes No SUBJECTS STUDIED COLLEGE NAME & LOCATION OF SCHOOL YEARS ATTENDED DID YOU GRADUATE? Yes No SUBJECTS STUDIED OTHER SCHOOLING NAME & LOCATION OF SCHOOL YEARS ATTENDED DID YOU GRADUATE? Yes No SUBJECTS STUDIED GENERAL INFORMATION SUBJECTS OF SPECIAL STUDY/RESEARCH WORK OR SPECIAL TRAINING/SKILLS HOBBIES AND INTERESTS: US MILITARY OR NAVAL SERVICE RANK AUTHORIZATION "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references 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 utilization of such information. "I also understand and agree that no representative of the company has any authority to enter into any agreement for employment 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." DATE SIGNATURE (type name)