Application For Employment > Please Carefully Fill Out The Following Application Application for Employment Step 1 of 4 25% This is a very significant document. You should be very careful as you complete it. Answer each item accurately and completely. Failure to do so may result in you not being considered for the position or in your termination if inaccurate or omitted information is discovered after your employment has begun. Do not simply write “see resume.” complete responses are required for each item.Personal InformationYour Full Name(Required) First Middle Last Social Security Number (Last Four Digits Only)(Required)Your Phone No.(Required)Email(Required) Resume Upload(Required)Max. file size: 3 MB.List all other names by which you have ever worked or been educated(Note: This information is only necessary for verification of your prior work history and education.) Present Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Permanent Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are you 18 years or older?(Required) Yes No Can you furnish proof that you have the right to employment in the U.S.?(Required) Yes No Employment DesiredPosition(Required) Date You Can Start(Required) Salary Desired(Required) Are you available to work:(Required) Full-Time Part-Time Are you employed now?(Required) Yes No If so, may we inquire of your present employer?(Required) Yes No I am not currently employed Who referred you to our company? Ever applied to our company before?(Required) Yes No Where?(Required) When?(Required) Ever worked for our company before?(Required) Yes No Where?(Required) When?(Required) Was termination voluntary or involuntary?(Required) Voluntary Involuntary I was not terminated Exact reason(s) for leaving(Required)Name of last supervisor at our company?(Required) Name(s) of all relatives who work for the company? Name(s) of all friends and acquaintances who work for the company Former Employers(List ALL current and past employers, starting with the most recent one)1. Name and address of present or last employer(Required)Starting Date (Month, Year)(Required) Leaving Date (Month, Year) Job Title(Required) May we contact immediate supervisor?(Required) Yes No Name and title of immediate supervisor Phone No.Description of Work(Required)Was termination voluntary or involuntary? Voluntary Involuntary Exact reason(s) for leaving2. Name and address of next previous employerStarting Date (Month, Year) Leaving Date (Month, Year) Job Title May we contact immediate supervisor? Yes No Name and title of immediate supervisor Phone No.Description of WorkWas termination voluntary or involuntary? Voluntary Involuntary Exact reason(s) for leaving3. Name and address of next previous employerStarting Date (Month, Year) Leaving Date (Month, Year) Job Title May we contact immediate supervisor? Yes No Name and title of immediate supervisor Phone No.Description of WorkWas termination voluntary or involuntary? Voluntary Involuntary Exact reason(s) for leavingUnemployment HistoryPlease account for any time you were not employed in the last 10 years, after leaving school. (you need not list any unemployed periods of one month or less.) (note: periods of unemployment will not necessarily disqualify an applicant.)Unemployment HistoryPlease click the + sign for more lines if needed. Time PeriodReason(s) Unemployed Add RemoveEducationHigh Schools:Please click the + sign for more lines if needed.Name & Location of School(s)No. of Years AttendedDid You Graduate?Mjr/Mnr Studied Add RemoveCollege(s)Please click the + sign for more lines if needed.Name & Location of School(s)No. of Years AttendedDid You Graduate?Mjr/Mnr Studied Add RemoveTrade, Business or Corresp. School(s)Please click the + sign for more lines if needed.Name & Location of School(s)No. of Years AttendedDid You Graduate?Mjr/Mnr Studied Add Remove MiscellaneousSubjects of special study or research work Special Training Special Skills Licenses and Certifications Do you have any commitments to another entity, business, or person that might interfere with your employment with our company, such as being subject to a restrictive covenant, to a trade secrets agreement, to recall from layoff, or holding a second job?(Required) Yes No Explain Fully(Required)Performance of Job-Related FunctionsAre you able to perform the essential functions of the job, with or without reasonable accommodation, for which you are applying?(Required) Yes No Do you currently take any illegal drugs?(Required) Yes No Describe Fully(Required)Do you use alcohol to the extent that you would be prevented from performing the essential functions of the job for which you are applying, with or without reasonable accommodation?(Required) Yes No Describe Fully(Required)If requested, are you available to work (check as many that would apply)(Required) Weekends Evenings Days Overtime ReferencesGive the names of three persons not related to you whom you have known at least one year.Reference 1(Required)NameAddressPhoneYears AcquaintedReference 2(Required)NameAddressPhoneYears AcquaintedReference 3(Required)NameAddressPhoneYears AcquaintedFrom time to time, the company may obtain information about you from public records. If you wish to waive your right to receive a copy of any public record, you should check the following box: I wish to waive my right AuthorizationsPLEASE READ CAREFULLY AND INITIAL EACH AUTHORIZATION PARAGRAPH BEFORE SIGNINGTruthful Statements(Required) “I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA AND THE UNITED STATES OF AMERICA THAT THE FACTS CONTAINED IN THIS APPLICATION OR ANY RESUME OR OTHER DOCUMENTATION SUBMITTED ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE INFORMATION OR SIGNIFICANT OMISSIONS WILL DISQUALIFY ME FROM FURTHER CONSIDERATION FOR EMPLOYMENT, AND WILL BE JUSTIFICATION FOR MY DISMISSAL FROM EMPLOYMENT, IF DISCOVERED AT A LATER DATE.” Criminal Matters(Required)“I AGREE TO IMMEDIATELY NOTIFY THE COMPANY IF I SHOULD BE CONVICTED OF OR PLEAD GUILTY OR NOLO CONTENDERE TO ANY CRIME DURING MY PERIOD OF EMPLOYMENT, IF HIRED.” Investigation of Information(Required)“I AUTHORIZE THE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION (AND ACCOMPANYING RESUME OR OTHER DOCUMENTATION, IF ANY) AND FURTHER AUTHORIZE ANY PERSON, SCHOOL, CURRENT EMPLOYER (EXCEPT AS EXPRESSLY NOTED), PAST EMPLOYER(S), CONSUMER REPORTING AGENCY AND ORGANIZATIONS, WHETHER OR NOT NAMED IN THIS APPLICATION FORM (AND ACCOMPANYING RESUME OR OTHER DOCUMENTATION, IF ANY), TO PROVIDE THE COMPANY WITH RECORDS, INFORMATION AND OPINION THAT MAY BE LAWFULLY USED IN MAKING A HIRING DECISION. I RELEASE ALL SUCH INFORMANTS AND THE COMPANY FROM ALL LIABILITY FOR ANY DECISION, CLAIM OR DAMAGE THAT MAY RESULT FROM FURNISHING AND/OR RELYING ON SUCH INFORMATION AND OPINION (WHICH IS TRUTHFUL OR MADE IN GOOD FAITH) TO YOU.” Drug Screening and Medical Examinations(Required)“I GIVE PERMISSION FOR A PRE-EMPLOYMENT DRUG SCREENING EXAM AND, IF THE COMPANY MAKES A CONDITIONAL JOB OFFER, I GIVE PERMISSION FOR A MEDICAL EXAMINATION. I ALSO CONSENT TO THE APPROPRIATE RELEASE OF THE RESULTS OF THE PRE-EMPLOYMENT DRUG SCREENING AND OF THE MEDICAL EXAMINATION, AS MAY BE DEEMED NECESSARY, AND AGREE TO EXECUTE ANY RELEASE OR OTHER DOCUMENTATION NECESSARY TO EFFECTUATE THIS CONSENT.” Company Business and Confidential or Trade Secret Information(Required)“I UNDERSTAND THAT, IF HIRED, AND DURING MY EMPLOYMENT, I SHALL ALWAYS GIVE PREFERENCE TO THIS COMPANY’S BUSINESS. I FURTHER AGREE NOT TO USE OR DISCLOSE COMPANY TRADE SECRETS OR CONFIDENTIAL OR PROPRIETARY INFORMATION TO ANYONE OUTSIDE THE COMPANY OR ANYONE WITHIN THE COMPANY WHO IS NOT AUTHORIZED TO HAVE THE INFORMATION. I FURTHER AGREE TO EXECUTE ANY DOCUMENTATION NECESSARY TO EFFECTUATE THIS PROVISION. I WILL NOT ENGAGE IN OTHER ACTIVITIES THAT CREATE A CONFLICT OF INTEREST WITH MY POSITION WITH THE COMPANY UNLESS GIVEN PERMISSION IN WRITING BY THE COMPANY.” Agreement for At-Will Employment(Required)“IF I BECOME EMPLOYED, IN CONSIDERATION OF MY EMPLOYMENT, I AGREE THAT MY EMPLOYMENT WILL BE AT-WILL, AND MAY BE TERMINATED WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME AT THE OPTION OF MYSELF OR THE COMPANY. I UNDERSTAND AND ACKNOWLEDGE THAT ONLY THE PRESIDENT OF THE COMPANY HAS THE AUTHORITY TO ENTER INTO AN EMPLOYMENT AGREEMENT FOR A SPECIFIED PERIOD OF TIME OR FOR TERMINATION ONLY FOR CAUSE, AND ANY SUCH AGREEMENT MUST BE IN WRITING. I UNDERSTAND AND ACKNOWLEDGE THAT THIS CONSTITUTES THE ENTIRE AGREEMENT BETWEEN ME AND THE COMPANY REGARDING THE TERM OF MY EMPLOYMENT AND SUPERSEDES ANY OTHER ORAL OR WRITTEN AGREEMENT.” Compliance With Rules(Required)“IF I BECOME EMPLOYED, IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO COMPLY WITH THE RULES, REGULATIONS, POLICIES AND PROCEDURES OF THE COMPANY.” Pre-Employment Documents(Required)“IF OFFERED EMPLOYMENT, I UNDERSTAND THAT I WILL BE REQUIRED TO REVIEW, COMPLETE AND EXECUTE VARIOUS EMPLOYMENT DOCUMENTS (INCLUDING, BUT NOT LIMITED TO, THIS APPLICATION, EMPLOYEE HANDBOOK AND EMPLOYEE HANDBOOK RECEIPT FORM, AND CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENTS), AND AGREE THAT THE PROCESS OF MY BEING HIRED WILL NOT BE COMPLETE UNTIL ALL EMPLOYMENT DOCUMENTS HAVE BEEN SIGNED.” Company Problem Resolution Procedure and Mutual Agreement to Mediate and/or Arbitrate(Required)“IF OFFERED EMPLOYMENT, I UNDERSTAND THAT A CONDITION OF EMPLOYMENT IS TO AGREE TO THE COMPANY’S PROBLEM RESOLUTION PROCEDURE WHICH INCLUDES A MUTUAL AGREEMENT TO ARBITRATE AS A FINAL AND BINDING STEP, AND I AGREE THAT THE PROCESS OF MY BECOMING EMPLOYED WILL NOT BE COMPLETE UNTIL I HAVE SIGNED ALL EMPLOYMENT DOCUMENTS, INCLUDING, BUT NOT LIMITED TO, THE MUTUAL AGREEMENT TO ARBITRATE.” Pre-employment Mutual Agreement to Mediate and/or Arbitrate(Required)“I UNDERSTAND THAT BY SIGNING AND SUBMITTING THIS APPLICATION, I AGREE TO THE EXCLUSIVE, FINAL AND BINDING RESOLUTION OF ALL DISPUTES OR CLAIMS OF ANY KIND ARISING OUT OF OR RELATING TO MY APPLICATION FOR EMPLOYMENT WITH THE COMPANY AND THE COMPANY’S DECISION WHETHER TO HIRE ME BY THE TERMS AND PROCEDURES SET FORTH IN THE COMPANY’S MUTUAL AGREEMENT TO ARBITRATE CLAIMS. I MAY REVIEW A COPY OF THE MUTUAL AGREEMENT TO ARBITRATE UPON REQUEST. I ALSO UNDERSTAND THAT IF I DO NOT SIGN THE APPLICATION AND AGREE TO SUBMIT ALL COVERED CLAIMS TO THE MUTUAL AGREEMENT TO ARBITRATE, I WILL NOT BE ELIGIBLE FOR EMPLOYMENT WITH THE COMPANY.” Today's Date(Required) MM slash DD slash YYYY Electronic Signature(Required) First Last PhoneThis field is for validation purposes and should be left unchanged.
