AUTHORIZATION AND ACKNOWLEDGMENT

I hereby certify that all of the information in this application is complete and accurate to the best of my knowledge and belief. I understand and agree that any omissions or false or inaccurate statement in my application or interview may be justification for refusal to hire or termination of employment if I am hired, regardless of the time lapse until discovery.

(Initial)

I hereby authorize the company and/or its representatives to investigate all references, to contact all prior employers and to secure additional information about me concerning my qualifications for the position applied for. I hereby release from liability the Company and its representatives for seeking such information.

(Initial)

I hereby authorize all prior employers, schools, credit bureaus, Social Security Administration, law enforcement agencies, consumer reporting agencies, investigative companies and any other persons, companies or governmental or other agencies to give the Company any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, concerning my qualifications for the position applied for. I release all persons or entities from all liability for any damage or injury that may result from furnishing information to the Company. I also release the Company and all of its employees from all liability for any damage or injury that may result from reliance on the information furnished.

(Initial)

I understand and agree that nothing contained in this application packet or in the hiring process is intended to create or does create an employment contract. I understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute an implied or express contract of employment. I understand and agree that if hired my employment is at-will, and therefore, my employment can terminate, with or without cause, at any time at my option or the option of the Company.

(Initial)

I acknowledge that any offer of employment with the Company is conditional upon passing the Company’s health screening. The health screening includes the completion a Post-Offer Pre-Employment Health Questionnaire along with a physical exam and passing the test of a urine sample to determine the presence of certain drugs and/or alcohol in the body.

(Initial)

No offer of employment with the Company is final until a prospective employee has passed a criminal background check. I understand that fingerprinting and criminal history investigations for employees are required by law and company policy in order for the community to maintain its licenses with governmental entities. I also understand that prior to the commencement of any employment with the Company and, if I am employed, during my employment with the Company, my fingerprints may be required and an investigation into my criminal history may be conducted pursuant to the applicable laws and requirements. With this understanding, I knowingly and voluntarily consent to the use of my fingerprints and criminal history by the Company or any governmental entity for employment and licensing purposes.

(Initial)

Further, I authorize any law enforcement agency (federal, state or local) to provide any record or information concerning my criminal history to the Company or any governmental entity for such purposes.

(Initial)

The Company reserves the right to conduct searches on Company property or of the Company’s property, vehicles and/or equipment at any time. I further understand that if I refuse to submit to a Company search, I may be terminated.

(Initial)

I understand and agree that this application will remain active for 90 days. If I still want to be considered for a position with the Company after this application expires, it is my responsibility to complete a new application.

(Initial)

Applicant Signature

By signing your full legal name, this counts as your legal signature.

Date

Resume

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Application for Employment

APPLICANT INFORMATION

GENERAL INFORMATION

WORK EXPERIENCE

EMPLOYMENT #1

EMPLOYMENT #2

EMPLOYMENT #3

EDUCATION

College University

Graduate School

Other (Business, Technical, Secretarial)

SKILLS AND QUALIFICATIONS

REFERENCES

Contact

Background Record

AUTHORIZATION AND ACKNOWLEDGMENT