Provide the following information of your past and current employers, assignments or Volunteer activities, starting with the most recent. Also provide any time gaps in employment.

Example: Employer, Phone Number, Address, Starting Job Title/Final Job Title, Immediate Supervisor/Title, Starting/Final Hourly Rates/Salary, Dates Employed From/To, Type Of Work/Job Responsibilities, Reason For Leaving & May We Contact The Employer For Reference.

List last three (3) schools attended, starting with most recent. List number of years completed. Indicate degree or diploma earned, if any. Grade point average or class rank. Major field of study. Minor field of study (if applicable).

List name and telephone number of three (3) business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

List professional, trade, business or civic associations and any offices held. Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.

A Brief Description Of Any Of These Items Can Be Added At The Bottom Of This Section.

Resume submissions are optional.

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 misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its 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, resumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no questions 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 prior 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 contrary 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 of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

DO NOT CONTINUE BELOW UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. *