Personal Information Name:  Last  First  MI     SSN Present Address      City State Zip Permanent Address      City State Zip Phone Are you 18 years or older?  Yes     No Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?  Yes  No Have you been convicted of a felony in the last seven years? Yes     No If yes, please explain:  (Conviction will not necessarily disqualify applicant from employment.  The recency, severity and pertinence of the conviction, as it pertains to the job, will be considered.) Employment Desired Position: Start date: Desired salary: Are you employed now ? Yes     No May we inquire of your present employer? Yes     No Have you ever applied to this company before? Yes     No Are you available to work:   Full Time         Part Time            Temporary What days?:  Sun     Mon     Tue     Wed     Thu     Fri     Sat Are you on lay-off and subject to recall? Yes     No Are you in the Military/National Guard?  Rank: Yes     No Education History   Name & Location Number of Years Graduate? Subjects Grammar School Yes No High School Yes No College Yes No Trade or Business School Yes No             General Information Special Skills Former Employers  (List below last three employers, starting with the last one first.) Date Month and Year Employer Name and Address Salary Position Reason for Leaving   Reason for Leaving   Reason for Leaving References (Give the names of three persons not related to you, whom you have known at least one year) Name Address Business Years Known References By submitting the above information, you certify that all the information on this application is true and complete, and you understand that if any false information, omissions, or misrepresentations are discovered, your application may be rejected and, if you are employed, your employment may be terminated at anytime.