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EMPLOYMENT APPLICATION
Please answer all questions.

We are an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

This company is an at-will employer as allowed by applicable state law. This means that regardless of any provision in this application, if hired, the company may terminate the employment relationship at any time, for any reason, with or without cause or notice.
APPLICANT INFO
Applicant Name:
Address:
Apt:
City:
State:
Zip:
Email:
Phone:
ADDITIONAL QUESTIONS
Desired Salary/Hourly Rate:
Desired Employment Status
Willing To Work Overtime

Previously Worked Here?
If Yes, When:
WORK AVAILABILITY
When can you start?

SUN: Start: End:
MON: Start: End:
TUE: Start: End:
WED: Start: End:
THU: Start: End:
FRI: Start: End:
SAT: Start: End:
EDUCATION
High School:
Address:
Years Attended:
Did you graduate?
Degree:


College:
Address:
Years Attended:
Did you graduate?
Degree:


Other:
Address:
Years Attended:
Did you graduate?
Degree:
REFERENCES
Please list three. Make sure that the phone number and email address are current.
Full Name:
Company:
Email Address:
Phone:
Relationship:

Full Name:
Company:
Email Address:
Phone:
Relationship:

Full Name:
Company:
Email Address:
Phone:
Relationship:
WORK HISTORY
Most Recent Employer:
Phone:
Address:
Supervisor:
Job Title:
When Employed:
Responsibilities:
Starting Salary:
Ending Salary:
Reason For Leaving:

May we contact your previous supervisor for a reference?


Next Most Recent Employer:
Phone:
Address:
Supervisor:
Job Title:
When Employed:
Responsibilities:
Starting Salary:
Ending Salary:
Reason For Leaving:

May we contact your previous supervisor for a reference?


Next Most Recent Employer:
Phone:
Address:
Supervisor:
Job Title:
When Employed:
Responsibilities:
Starting Salary:
Ending Salary:
Reason For Leaving:

May we contact your previous supervisor for a reference?
APPLICANT CERTIFICATION
I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid NYS drivers license and automobile liability insurance in an amount equal to the minimum required by the New York State.

I understand that the company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state and local law. If the company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post offer) drug and/or alcohol test is positive, the employment may be withdrawn. I agree to work under the conditions requiring a drug free workplace, consistent with applicable federal, state and local law. I also understand that all employees of the location, pursuant to the company's policy and federal, state and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed, I understand that the taking of alcohol and/or drug tests, is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the company's policies and applicable federal, state and local law.

If employed by the company, I understand and agree that the company, to the extent permitted by federal, state and local law, may exercise its right, without prior warning or notice, to conduct investigation of property (including, but not limited to, files, lockers, desks, vehicles and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment, and to the extent permitted by federal, state and local law, I may be required to sign confidentiality, restrictive covenant and/or conflict of interest statement, as well as an agreement to arbitrate.

I certify that all the information on this application, my resume, or any supporting documents I may present during any 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.

If hired, 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 its policy of employment at-will.

I authorize the company or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking to the extent permitted by federal, state and local law. I agree to complete any requisite authorization forms for the background investigation which may be permitted by federal, state and local law. If applicable, I will receive separate written notification regarding the company's intent to obtain "consumer reports."

I authorize and consent to, without reservation, any party or agency contacted 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 duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a 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, corporations or organizations furnishing such information. Further, if hired, I authorize the company to provide truthful information concerning my employment to future employers and hold the company harmless for providing 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 United States by this company. I also understand that this company employs only individuals who are legally eligible to work in the United States.

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 RE-APPLY.

I CERTIFY THAT ALL THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE AND COMPLETE.

DO NOT SUBMIT THIS FORM UNTIL YOU HAVE READ ALL THE INFORMATION CONTAINED IN THE APPLICATION.
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