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If you are under 18, and it is required, can you furnish a work permit?	YES NO
If no, please explain
Have you ever been employed here before?	YES NO
If yes, give dates and positions.
Are you legally eligible for employment in this country?	YES NO
Date available for work
What is your desired salary range?
Type of work desired
Full-Time Part-Time Temporary Seasonal Educational Co-Op
Are you able to meet the attendance requirements of the position?	YES NO
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?	YES NO
If yes, please provide dates and details
Answering "yes" to these questions does not constitute and automatic bar to employment. Factors such as date of the offense and nature of the violation, rehabilitation and position applied for will be taken into account.
Driver's license number if driving is an essential job function
STATE

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Employment History (1) Provide the following information of your past (3) employers, assignments, or volunteer activities, starting with the most recent.
FROM	TO	EMPLOYER	TELEPHONE
Starting Job Title		Final Job Title	Immediate Supervisor/Title
May we contact for a reference?			YES NO LATER
Summarize the nature of work performed and job responsibilities
Reason for leaving
Hourly rate/Salary
Start Final

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Employment History (2)
FROM	TO	EMPLOYER	TELEPHONE
Starting Job Title		Final Job Title	Immediate Supervisor/Title
May we contact for a reference?			YES NO LATER
Summarize the nature of work performed and job responsibilities
Reason for leaving
Hourly rate/Salary
Start Final

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Employment History (3)
FROM	TO	EMPLOYER	TELEPHONE
Starting Job Title		Final Job Title	Immediate Supervisor/Title
May we contact for a reference?			YES NO LATER
Summarize the nature of work performed and job responsibilities
Reason for leaving
Hourly rate/Salary
Start Final

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Skills and Qualifications Summarize any training, skills, licenses or certifications that may quality you as being able to perform job-related functions in the position for which you are applying.
Educational Background (if job related)
High School	NUMBER OF YEARS COMPLETED	DID YOU GRADUATE? YES NO
Course of study
College	NUMBER OF YEARS COMPLETED	DID YOU GRADUATE? YES NO
Course of study
Other	NUMBER OF YEARS COMPLETED	DID YOU GRADUATE? YES NO
Course of study
Other	NUMBER OF YEARS COMPLETED	DID YOU GRADUATE? YES NO
Course of study

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References
Name	Telephone	Years Known

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Applicant Statement - You must read and agree in order to send application

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete, or misinterpreted in any respect will be sufficient cause to (1) cancel further consideration of this application, or (2) immediately discharge me from the employer's service, whenever it is discovered. I expressly authorize, without reservation, the employer, the representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by Applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contract to the foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof or identity and legal authority to work in the United States and that federal immigration laws require me to complete and I-9 Form in this regard.

I certify that I have read, understand, and accept the terms of the above Applicant Statement. In lieu of your signature, please check here:  YES You must check "YES" that you agree in order to submit your application. If you are printing and mailing this application to AwnClean, please sign below: ____________________________________________________________________________