Fillable Employment Application (Page 2 of 3) in pdf

Yes:

No:

Personal References

Reference 1

Reference 2

Reference 3

Name

Address

City, ST, ZIP

Telephone

Please Answer the Following Questions:

1. Have you ever pleaded Guilty or No Contest to, or been convicted of any criminal offense, other that the applicable exceptions listed below?

Yes:

No:

* Do not include misdemeanor marijuana-related convictions that are more than two (2) years old misdemeanor convictions

for which probation was successfully completed or otherwise discharged and the case was judicially dismissed

* Do not include convictions that were sealed, eradicated, erased, annulled by a court, or expunged, or convictions that resulted in referral to a diversion program.

2. Have you even been arrested for any matters for which you are out of bail or on your own recognizance pending trial?

Yes:

No:

Criminal Offenses Only:

If you answered YES, to either of the above two questions, please provide the date(s) and explain in accordance with the above

instructions so that individual circumstances can be considered.

Criminal convictions will not automatically disqualify an applicant from a particular job. The Company will consider the nature of the crime, its seriousness, where the conviction (s)

substantially relates to the position functions and qualifications, the frequency of convictions, the applicant's age at the time of the 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.

3. Have you ever initiated an act of violence in the workplace?

Yes:

No:

If YES, please provide the date (s) and explain so that individual circumstances can be considered. (A "Yes" answer will not necessarily disqualify you from employment)

Please Read and Sign:

We require completion of a background check in order to qualify for this job. This includes checking FBI records in order to verify any criminal history. Disclosure of any Crimina l

History prior to performing this check will assist us in determining if you qualify for this job. We will also verify Employment History and require various documents

upon hiringincluding: Driver's License, Social Security card, Academic Transcripts, Verification of Immigration status (if applicable), Automobile Insurance,

TB test within the last 2 years, Vaccination records, Statement by a Physician authorizing that Employee is physically capable of performing services, and other documents.

By signing below, you agree to perform the fingerprinting required of a background check, and grant us permission to receive and verify any information provided on this applica tion.

DISCLAIMER- By signing, I hereby certify that the above information, to the best of my knowledge, is correct. I understand that falsification of this information may prevent me

from being hired or lead to my dismissal if hired.

Name:

Signature:

Date:

Employment Application Page 2

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