- Employment Application -

	Personal Information *First Name:    *Middle Int.:     *Last Name: *Address: *City:    *State:     *Zip Code:     Social Security #: *Phone:    Fax:    *Email Address:

	Employment Desired Position:    Start Date:    Desired Salary:   Are you Employed Now: Yes     No If so, where:   Ever applied before: Yes     No If so, when & what position:

	Educational Experience Please list at least one school attended, preferably your high school, along with any other school you attended after high school, such as college, business or technical school. School 1         Name:       Location         How long did you attend? Months Years   Month and Year you graduated?     Major areas of Study   Degree Earned   Average GPA or Grade           School 2         Name:       Location         How long did you attend? Months Years   Month and Year you graduated?     Major areas of Study   Degree Earned   Average GPA or Grade

	Have you ever been arrested for other than a minor traffic offense? (If yes, furnish details & disposition) Foreign languages spoken,read, written:   U.S. Military or Naval Service:     Rank: Activities other than Religious: (exclude organizations, the name or character of which indicates the race, creed, color or national origin of its members) *THE LAW IN NEW YORK, MASSACHUSETTS, COLORADO, LOUISIANA, PENNSYLVANIA, RHODE ISLAND, AND CERTAIN OTHER STATES PROHIBITS DISCRIMINATION BECAUSE OF AGE.

	Employment History Employer 1   Name: From: Salary: To: Position: Reason for Leaving: Employer 2   Name: From: Salary: To: Position: Reason for Leaving:

	References Reference 1   Name:     Years Known Address: Business: Reference 2   Name:     Years Known Address: Business: Reference 3   Name:     Years Known Address: Business:

	Physical Record Please list any physical defects. Were you ever injured? Yes   No In case of emergency notify:   Name: Address: Phone:

	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 an 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. Date:      Signature: Additional Information or Comments: