Please specify all a.m. and p.m. hours and the days you are available to work.
Education, Training and Experience
Please describe past and present employment positions, dating back five years. Please
account for all periods of unemployment. Even if you have attached a resume, this section must be
List below three persons who have knowledge of your work performance within the last four years.
Please include professional references only.
Please read and initial each paragraph, then sign and date below.
I certify that I have not purposely withheld any information that might adversely affect my
chances for hiring. I attest to the fact that the answers given by me are true & correct to the best
of my knowledge and ability. I understand that any omission (including any misstatement) of
material fact on this application or on any document used to secure can be grounds for rejection
of application or, if I am employed by this company, terms for my immediate expulsion from the
I understand that if I am employed, my employment is not definite and can be terminated at any
time either with or without prior notice, and by either me or the company.
I permit the company to examine my references, record of employment, education record, and
any other information I have provided. I authorize the references I have listed to disclose any
information related to my work record and my professional experiences with them, without giving
me prior notice of such disclosure. In addition, I release the company, my former employers & all
other persons, corporations, partnerships & associations from any & all claims, demands or
liabilities arising out of or in any way related to such examination or revelation.