Online Employment Application Personal Information Name Last Name First Name Present Address Address City State Zip Code Permanent Address Address City State Zip Code Contact Information Phone Secondary Phone Email Referred By Employment Desired Position Date you can start Salary Desired Are you employed now? Yes No If so, may we inquire of your present employer? Yes No Are you legally authorized to work in the U.S.? Yes No Ever applied to this company before? Yes No Where When Ever worked for this company before? Yes No Where When Reason for leaving Name of last supervisor at this company How did you find out about this position? Employment Agency State Employment Office Newspaper Advertising College Placement Service Friend Walk In Online Ad Other Website Education History High School College Trade School Name & Location of School High School College Trade School Years Attended High School College Trade School Did You Graduate High School College Trade School Subject Studied High School College Trade School General Information Subject of special study/research work Special training, certifications, licenses Special skills, foreign languages, etc. Military Service Record Have you ever served in the U.S. Armed Forces Yes No Branch of Service Discharge Date Rank Former Employers (List below last three employers, starting with most recent) Employer #1 Name of present or last employer Address City State Zip Starting Date Leaving Date Job Title Weekly Starting Salary Weekly Final Salary May we contact your supervisor? Yes No Name of supervisor Title Phone Description of work Reason for leaving Employer #2 Name of present or last employer Address City State Zip Starting Date Leaving Date Job Title Weekly Starting Salary Weekly Final Salary May we contact your supervisor? Yes No Name of supervisor Title Phone Description of work Reason for leaving Employer #3 Name of present or last employer Address City State Zip Starting Date Leaving Date Job Title Weekly Starting Salary Weekly Final Salary May we contact your supervisor? Yes No Name of supervisor Title Phone Description of work Reason for leaving References (List professional references whom we may contact) Name Reference 1 Reference 2 Reference 3 Address Reference 1 Reference 2 Reference 3 Business Reference 1 Reference 2 Reference 3 Phone Reference 1 Reference 2 Reference 3 Special Purpose Questions Height Ft Height Inches Weight Lbs. Are you a U.S. Citizen? Yes No Have you been convicted of a Felony or Misdemeanor within the last 5 years? Felony Misdemeanor None If Yes, Describe You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied. I understand and agree that I may be required to take one or more: drug test(s), as a condition of hiring or continued employment. I agree to consent to take test(s) at such time as designated by the Company and to release the company, its directors, officers, agents or employees from any claim arising in connection with the use of such test(s) Are you able to perform each of the following job functions with or without an accommodation? Lift 70 lbs. on a regular basis Yes No If you can perform the function with an accommodation, explain how you would perform the tasks, and with what accommodation? Climb and work from a ladder/aerial lift Yes No If you can perform the function with an accommodation, explain how you would perform the tasks, and with what accommodation? Were you ever seriously injured? Yes No If yes, give details Are you a registered sex offender? Yes No 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." Signature Date Signature