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Personal Information

Date

Email

Social Security Number

California Driver's License Number

Last Name

First Name

Middle Name

Other names used

Addresses (please list for the last 7 years)

Street

City

State

Zip

Street

City

State

Zip

Residential addresses for the past 5 years

From

To

Address

City

State

Zip

From

To

Address

City

State

Zip

From

To

Street

City

State

Zip

Phone numbers

Daytime number

Evening number

Employment desired

Date you can start

Position

What pay do you expect?

Your present employer?

If so, may we contact?

Are you employed now?

Are you available to work:

Education and skills

Language (1st)

Speak

Read

Write

Language (2nd)

Speak

Read

Write

Elementary School (name and location)

Years completed

High School (name and location)

Years completed

High school diploma

Undergraduate College/University (name and location)

Years completed

Degree/diploma name and classification

Graduate/Professional (name and location)

Years completed

Degree/diploma name and classification

Describe any specialized training, apprenticeship, skills or extra-curricular activities that are relevant to the job for which you are applying

Describe any honors, scholarships, appointments or awards that you have received:

State any additional information you feel may be helpful to us in considering your application:

List professional, trade, business or civil activities and offices held. You may exclude information that would reveal sex, race, religion, national origin, age, ancestry, or disability or other protected status or personal information:

List any professional or vocational certificates, licenses, or registrations that you currently hold or have held in the past:

List any job-related professional or technical organizations to which you belong:

State

Number

Expiration date

Class

Restrictions or Suspensions (respond fully if driving is required by the job for which you are applying):

Additional information

U.S. Military or Naval Service?

Rank

Citations/awards

List any job-related skills that you learned while in the U.S. Military or Naval Service:

Are you over 18 years of age?

Have you been convicted of a crime? (Convictions will not necessarily disqualify an applicant from employment. Do not provide information about misdemeanor marijuana convictions more than 2 years old).

If yes, explain:

Have you used illegal drugs within the past three (3) weeks?

If yes, which illegal drugs did you use?

Are you currently under arrest for any crime, other than for possession of less than one ounce of marijuana more than two years ago, which has not been resolved (i.e., pending trial, etc.)?

Are you able to perform the duties of the position for which you are applying, including regular attendance?

Have you been discharged or asked to resign from a positions or a job?

If yes, explain reasons:

References

Referee Name (1st)

Address

Telephone number

Years acquainted

Referee Name (2nd)

Address

Telephone number

Years acquainted

Referee Name (3rd)

Address

Telephone number

Years acquainted

Former employers

Employer (1st)

From

To

Work performed

Address

Telephone number(s)

Starting pay

Final pay

Job title

Supervisor

Reason for leaving

Employer (2nd)

From

To

Work performed

Address

Telephone number(s)

Starting pay

Final pay

Job title

Supervisor

Reason for leaving

Employer (3rd)

From

To

Work performed

Address

Telephone number(s)

Starting

Final

Job title

Supervisor

Reason for leaving

Employer (4th)

From

To

Work performed

Address

Telephone number(s)

Starting

Final

Job title

Supervisor

Reason for leaving

Performance evaluations

Did you receive written performance evaluations from any of your prior employers?

Employer (1st)

Frequency of evaluations (e.g., annual, biannual, etc.)

Signed?

Employer (2nd)

Frequency of evaluations (e.g., annual, biannual, etc.)

Signed?

Employer (3rd)

Frequency of evaluations (e.g., annual, biannual, etc.)

Signed?

Explain any gaps in your employment history. (Do not provide information about any physical or mental disabilities or other medical information.)

In case of emergency notify:

Name

Phone

Street

City

State

ZIP

I understand and acknowledge the following:

1. If I am offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the U.S. 2. I understand that, if I am employed, any false statement, misrepresentation, or omission of facts on this application or on any supporting documents, regardless of when discovered to be false or omitted, may result in my immediate dismissal. 3. I understand that I will be required to possess a current and valid California driver's license if my job requires me to drive in the course of my work. 4. I agree that, if I am offered a position, it will be offered on condition that my employment shall be at will and for no definite period, and that my employment may be terminated at any time with or without cause and with or without prior notice. 5. I understand and agree that, if I am offered a position, it will be a conditional offer based on my successful passing of both a drug and alcohol screen and a post-offer medical examination. 6. I understand and agree that as a condition of my employment I may be required to undergo a medical examination. 7. I understand and agree that as a condition of my employment, I may be required to undergo drug testing, and any other testing to the extent permitted by applicable laws. 8. I understand and agree to arbitrate any dispute or controversy, both statutory and non-statutory, concerning or in any way relating to my employment or prospective employment with the Company, in accordance with the rules of the Judicial Arbitration and Mediation Service or a mutually agreeable arbitrator. I further understand and agree that, as a condition of employment, I may be required to enter into an employment agreement which will, among other things, include an agreement to arbitrate all disputes arising out of my employment or the termination of my employment. 9. If I am offered employment, I will, as a condition of employment, furnish proof that I am over 18 years of age. 10. I agree that, if I am offered employment, I will be required to conform to the rules and regulations of the Company. 11. I authorize investigation of all statements contained in this application and any supporting documents. I authorize the Company to secure information about my experience from former employers, educational institutions, government agencies, or any references I have provided, and for those parties to provide information concerning my experience and I hereby release all parties from any liability arising from such investigation. 12. I understand that no supervisor or manager may alter or amend the conditions set forth in paragraphs one (1) through eleven (11) above. I understand that the foregoing conditions can only be altered or amended by a written agreement signed by the President of the Company.

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