Application for Employment Date: Position Applied For:   Full Name: Social Security #: Current Address: City, State, Zip:   Telephone Number: Secondary Phone Number: Type of Employment Desired? Full Time   Part Time   Are you willing to work overtime? Yes   No   Have you ever applied with this company before? Yes   No   If Yes, when did you apply?   Within the past ten (10) years, have you ever been convicted of a felony? (Do not include convictions that were sealed, eradicated, erased, or expunged; convictions that resulted in referral to a diversion program; marijuana related convictions that are more than two (2) years old.) Yes   No  If Yes, please explain so that individual circumstances can be considered. NOTE: Criminal convictions will not automatically disqualify an applicant from a particular job. The Company will consider the nature of the crime, it's seriousness, whether the conviction(s) substantially relate to the position's functions and qualifications, the frequency of convictions, the applicants age at the time of conviction, the time elapsed since the date of conviction or completion of jail sentence, the applicant's entire work and educational history, and employment references and recommendations. Have you ever initiated an act of violence in the workplace? Yes   No  If Yes, please explain so that individual circumstances can be considered. (A Yes answer will not necessarily disqualify you from employment.) EDUCATION: High School   Name of School Location Graduate? Yes   No   College   Name of School Location Graduate? Yes   No   Degree / Major Years completed WORK EXPERIENCE (Start with your present or most recent place of employment.) Job 1: Employer Address Phone Dates employed   to   May we contact? Yes   No   Duties Reason for leaving Job 2: Employer Address Phone Dates employed   to   May we contact? Yes   No   Duties Reason for leaving Job 3: Employer Address Phone Dates employed   to   May we contact? Yes   No   Duties Reason for leaving Job 4: Employer Address Phone Dates employed   to   May we contact? Yes   No   Duties Reason for leaving REFERENCES Please list the names of additional work-related references we may call. Reference 1: Name (First and Last) Phone (Include Area Code) Company Name Work Relationship Reference 2: Name (First and Last) Phone (Include Area Code) Company Name Work Relationship Reference 3: Name (First and Last) Phone (Include Area Code) Company Name Work Relationship Comments: After submitting this form, your application will be placed in a database and you will be contacted for an interview once a position comes available. Please note that all applications are kept for 120 days. Please feel free to re-submit after 120 days from first submission.