AN EQUAL OPPORTUNITY EMPLOYER: We do not discriminate on the basis of race, religion, national
origin, color, sex, age, marital status or disability.
General Information: Date: _____/_____/20____
Last Name: _____________________ First Name: _____________________ Middle Initial: ___________
Address (including Apt# and PO Box): ______________________________________________________
City: ____________________________________ State: _________ Zip Code: ___________-__________
Phone Number: (____) _____-_________
18 or older? YES _______ NO _______
Do you have a drivers license? Yes ______ No _______ State _________
Have you had your license revoked in the last 3 years? Yes_____ No _____
Have you ever been convicted of any law violation? Yes _____ No _____ If yes, please give details:
(A yes answer does not disqualify you from a position, since the offense will be taken into consideration depending
on the job you are applying for.)
What clubs, organizations, civic or other groups have you been a member in the last five years? Exclude any
labor organizations or any group that name and character indicated race, color, religion sex, age, national origin or
ancestry of its members.
Employment Desired:
Position Applying For: ________________________________________________________________________
Part-Time ________ Full-Time ________ Date Available to start: _____________ Wage Desired: ___________
Have You Applied to this Company Before? YES _____ NO _____ If Yes, When? ________________________
Day and Times Available to work: Sun Mon Tues Wed Thur Fri Sat
From: _____ _____ _____ _____ _____ _____ _____
To: _____ _____ _____ _____ _____ _____ _____
Education:
School Name Years Attended Did you Graduate? Degree GPA
High School: ____________ 9 10 11 12 YES NO ____________ _______
College: ____________ 1 2 3 4 YES NO ____________ _______
U.S. Military: _____________
Branch: ________________________________________________________________________
Special Training received: _________________________________________________________