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Full/Part Time Positions – $18/hr Starting Rate – Evenings and Weekends Required
Drivers License Required – The ability to drive a stick is preferred but not required
Must Pass Background & Drug Screen
Date of Birth
Social Security Number
Full name
Phone No.
Cell Phone
Email address
Home Addresses for the Past 7 Years
Present Address (optional)
from Mo/Yr (optional)
to Mo/Yr (optional)
Years Resided (optional)
Previous Address (optional)
from Mo/Yr (optional)
to Mo/Yr (optional)
Years Resided (optional)
Previous Address (optional)
from Mo/Yr (optional)
to Mo/Yr (optional)
Years Resided (optional)
Previous Address (optional)
from Mo/Yr (optional)
to Mo/Yr (optional)
Years Resided (optional)
Previous Address (optional)
from Mo/Yr (optional)
to Mo/Yr (optional)
Years Resided (optional)
Have you ever been convicted of a crime?
If Yes (optional)
List Date, City/County, State (optional)
Drivers License No.
Drivers License State
Drivers License Class
Have you ever been convicted of other than minor traffic violations?
If yes, give date and explain (optional)
GED
Date Received (optional)
Name of School (optional)
Address of School (optional)
Name of High School (optional)
from Mo/Yr (optional)
to Mo/Yr (optional)
Address of High School (optional)
Date Received (optional)
Name of Degree (optional)
Name of College (optional)
from Mo/Yr (optional)
to Mo/Yr (optional)
Address of College (optional)
Diploma Received (optional)
Date Received (optional)
Name of Degree (optional)
List Below Last Four Employers, Starting With Last One First
from Mo/Yr
to Mo/Yr
Employer Name
Phone No
Employer Address
Position
Reason for Leaving
from Mo/Yr (optional)
to Mo/Yr (optional)
Employer Name (optional)
Phone No (optional)
Employer Address (optional)
Position (optional)
Reason for Leaving (optional)
from Mo/Yr (optional)
to Mo/Yr (optional)
Employer Name (optional)
Phone No (optional)
Employer Address (optional)
Position (optional)
Reason for Leaving (optional)
from Mo/Yr (optional)
to Mo/Yr (optional)
Employer Name (optional)
Phone No (optional)
Employer Address (optional)
Position (optional)
Reason for Leaving (optional)
State Name and Location of Any Relatives, Other Than Spouse, Already Employed By This Company (optional)
Referred By (optional)
Give Below the Names of Three Persons Not Related To You, Whom You Have Known At Least One Year.
Name (optional)
Business (optional)
Address (optional)
Phone (optional)
Years Acquainted (optional)
Name (optional)
Business (optional)
Address (optional)
Phone (optional)
Years Acquainted (optional)
Name (optional)
Business (optional)
Address (optional)
Phone (optional)
Years Acquainted (optional)
Do you have any physical condition which may limit your ability to perform the job applied for? (optional)
In Case of Emergency Notify
Contact Name (optional)
Contact Address (optional)
Contact Phone (optional)
I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.