* = Required Information
We are an Equal Opportunity Employer. All persons shall have the opportunity to be considered for employment without regard to their race, color, religion, national origin, ancestry, alienage or citizenship status, age, disability, sex or gender, marital status, veteran status, or any other characteristic protected by applicable federal, state or local laws. We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please let us know.
Part Time Full Time
Present Address
Yes No
Yes No
Record of Education
Yes No
Yes No
Yes No
Yes No
Record of Previous Employment
Work Experience: Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including military service, work performed on a volunteer basis, and any period of unemployment. If self-employed, give firm name and supply business references.
Yes No
Yes No
Professional Licenses and Certifications:Please list all professional licenses and certifications held, including the expiration date for each.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Pursuant to the Immigration Reform and Control Act of 1986, all applicants who are offered employment must produce documents establishing their identity and authorization for employment in the United States. These documents must be produced no later than seventy-two (72) hours after employment commences. In addition, all new hires will be required to verify their employment authorization under oath by signing INS Form 1-9.
Yes No
Work Schedule Availability
*Scheduling will be based on business demands.
Yes No
Personal References
Please list persons who know you well, not previous employers or relatives
Business/Customer Referral EDD Job Fair College/HS/Trade School
Employment Agency Lobby/Walk-In Competitor Internet
APPLICANT'S STATEMENT & AGREEMENT
I have read and fully understand the questions asked in this application. I certify that all of the answers I have given are true, accurate and complete. I understand that the omission and/or misrepresentation of any fact from or on this application or any other documentation submitted in association with my consideration for hire,or otherwise during any interview will result in immediate rejection of my application, or if I am hired will be cause for immediate dismissal. Unless I noted otherwise, I authorize the Company to contact all my employment references and personal references, as well as the education institutions I have attended. I further authorize the Company to inquire about, investigate and obtain copies of any records which relate to me from my former employers and educational institutions. I hereby release the Company and all affiliated persons and entities, as well as any person or institution that provides the Company with any lawful information about me, from any and all liability whatsoever resulting from any such lawful inquiry, investigation or communication.

If hired, I agree to abide by all of the rules and regulations of the Company. I understand and agree that nothing in this application shall constitute an offer, a contract or a guarantee of employment for a specific period of time. If hired, I understand that my employment may be terminated with or without cause and with or without notice at any time, at the will of the Company or me. I further understand that no representative or agent of the Company, other than the company President, has the authority to enter into any agreement for employment for any specific period of time, or to make an agreement contrary to the foregoing. I also understand that any agreement modifying my at-will employment status must be in writing and signed by the company President. In addition, I understand that the Company and all plan administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms and conditions of employment.

I understand that any hiring decision is contingent upon my successful completion of all of the Company's lawful pre-employment checks, which will include a background check and pre-employment drug testing. I agree to execute any consent forms necessary for the Company to conduct its lawful pre-employment checks and drug testing.

READ CAREFULLY BEFORE SIGNING
I AGREE THAT ANY ACTION OR CLAIM AGAINST THE COMPANY, ITS AGENTS OR EMPLOYEES, ARISING OUT OF MY EMPLOYMENT OR TERMINATION OF EMPLOYMENT 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 STATUTE OF LIMITATIONS OR LIMITATIONS PERIOD TO THE CONTRARY.

If you have any questions regarding this statement, please ask a Company representative before signing. I hereby acknowledge that I have read the above statements and understand the same.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT & AGREEMENT
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