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Employment Application

PERSONAL INFORMATION
	First	Middle		Last
Name:
Email address				Social Security Number - -
Present Address:	Street	City		State	Zip
Permanent Address:	Street	City		State	Zip
Phone Number:	- -	Referred by
Position Desired		Salary Desired			When can you Start?
Are you employed?	Yes No	If Yes, may we contact your present employer? Yes No
Ever applied before?	Yes No	If Yes, when

EDUCATION HISTORY
Grammer School		Did you Graduate? Yes No	Years Attended		Subjects Studied
High School		Did you Graduate? Yes No		Years Attended	Subjects Studied
College		Did you Graduate? Yes No		Years Attended	Subjects Studied
Trade, Business or Correspondence School		Did you Graduate? Yes No		Years Attended	Subjects Studied
GENERAL INFORMATION
Subjects of Special Study/Research Work or Special Training/Skills
U.S. Military or Naval Service				Rank
FORMER EMPLOYERS (List Below Last Four Employers, Starting with Last One First)
Date (Month & Year)	Name & Address of Employer			Yearly Salary	Position	Reason for Leaving
From To	Employer 1
From To	Employer 2
From To	Employer 3
From To	Employer 4
REFERENCES
Name	Address			Years Known	Business



AUTHORIZATION
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."
By placing my initials and date in the spaces below and submitting this form, I am agreeing to the authorization as outlined in the stipulations above. Initials: Date:

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