Candidate's Name* Date* Street Address* City* State* AlabamaAlaskaArizonaArkansasArmy Post OfficeBritish ColumbiaCaliforniaColoradoConnecticutDelawareDiplomatic Post OfficeDistrict of ColumbiaFleet Post OfficeFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaManitobaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNova ScotiaNunavutOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Zip* Phone Number* Email* Are you 18 years of age or older? YesNo Are you either a U.S. citizen or an alien authorized to work in the U.S.? YesNo Have you ever worked or attended school under another name? If so, under what name? Have you ever been convicted of a crime?** YesNo If yes, give details, including date(s): Position Desired Position Start Date Available Wage Rate Desired Wage Rate Type HourlyMonthlyAnnually Do you prefer: Full TimePart Time If part-time, hours per week desired: Hours you are available to work: Days of week you are available to work: Are you able to work: Weekends (Saturday until 4:00 p.m.)OvertimeNights (until 8:00 p.m.) How did you learn about this opening? Education High School Graduated? YesNo Course of Study Technical School Graduated? YesNo Course of Study College/University Graduated? YesNo Course of Study Post-Graduate Education Graduated? YesNo Course of Study Other education, training or special skills: Work Experience Employer Employer Address What dates were you employed here? Position Held Reason for Leaving Supervisor's Name & Title May we contact? YesNo Description of Duties Starting Compensation Final Compensation Employer Employer Address What dates were you employed here? Position Held Reason for Leaving Supervisor's Name & Title May we contact? YesNo Description of Duties Starting Compensation Final Compensation Work References Identify three persons, beginning with the most recent. Name Phone Email Address Position/Title Years Known Name Phone Email Address Position/Title Years Known Name Phone Email Address Position/Title Years Known Please Attach Résumé (REQUIRED)* I have read the Authorization and Acknowledgements and agree to the terms (see below). * = Required Field Please read - Authorization and Acknowledgements I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for discharge. I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure. **Answering "yes" will not automatically disqualify you from employment. We will consider the nature and date of the offense and the job for which you are applying for job-related purposes only, and only to the extent permitted by law.