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Name Address Apt. City Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY State ZIP Code Home Phone Social Security Number   How did you learn about the Company? Position(s) applying for: Location preference(s) or geographic limitations: Hours per week: Full Time Part Time Are you willing to work weekends, holidays, and overtime? Yes      No Are you willing to relocate? Yes No If required by the position(s) for which you are applying, can you stand for long periods of time and lift 50 pounds? Yes No Date available to start work: Pay required: Have you ever applied to this Company before? Yes No If yes, give date(s): For what position(s)? Have you ever been employed by this Company before? Yes No If yes, give date(s): Position(s): Reason(s) for leaving:   Employment History List below present and past employment (full-time, part-time, and self-employment) beginning with your most recent position. Present or Most Recent Employer (1) Company Name: City: State: Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY ZIP Code: Your position: Your job duties: Dates employed: From      To Wage or Salary: Reason for leaving: Resigned Laid Off Discharged Other Explain the reason(s) or circumstance(s) for changing or wanting to change jobs: Were you ever disciplined, warned, or counseled about job performance, absenteeism, tardiness, or policy violations? Yes No If yes, please explain: If still employed, may we contact your employer? Yes No Next Previous Employer (2) Company Name: City: State: Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY ZIP Code: Your position: Your job duties: Dates employed: From      To Wage or Salary: Reason for leaving: Resigned Laid Off Discharged Other Explain the reason(s) or circumstance(s) for changing or wanting to change jobs: Were you ever disciplined, warned, or counseled about job performance, absenteeism, tardiness, or policy violations? Yes No If yes, please explain: Next Previous Employer (3) Company Name: City: State: Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY ZIP Code: Your position: Your job duties: Dates employed: From      To Wage or Salary: Reason for leaving: Resigned Laid Off Discharged Other Explain the reason(s) or circumstance(s) for changing or wanting to change jobs: Were you ever disciplined, warned, or counseled about job performance, absenteeism, tardiness, or policy violations? Yes No If yes, please explain: Other Information Are you legally entitled to work in the United States? Yes No Are you at least 18 years of age? Yes No Have you been convicted within the last five (5) years of a felony or of a misdemeanor which resulted in imprisonment and which has not been sealed or expunged from your record? (Applicants with sealed records on file with the commissioner of probation may answer "No Record" in all cases of delinquency or as a child in need of services which did not result in a complaint being transferred to the superior court for criminal prosecution.) Yes No If yes, please explain: (A conviction record will not necessarily be a bar to employment. Factors such as age and time of the offense, seriousness and nature of the offense, and rehabilitation will be taken into account.) Education High School (name and address): Last Year Completed: Graduated? 9 10 11 12 Yes No Major course: College (name and address): Last Year Completed: Graduated? 1 2 3 4 Yes No Major course: Trade/Other School (name and address): Last Year Completed: Graduated? 1 2 3 4 Yes No Major course: List any other schooling or training, including training received in the armed forces, that may relate to the type of position(s) you are seeking: Use the space below to describe your interest in this Company and the skills and aptitudes that you feel particularly qualify you for the type of position(s) you seek. Please include any job-related certificate or license you hold or any job-related equipment that you operate:   When you are ready to submit this application, click Submit below.