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PERSONAL DATA

Salary Expectations:
* First Name: Middle Name: * Last Name
* Email * Telephone
* Address * City * State * Zip
If you are under 18 years of age, please specify your age:

(This information will be used only for child labor law purposes).

Are there any days, shifts or hours you will not work? Yes No
Will you work overtime, If required? Yes No Are you available for out of town work? Yes No

* Note: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made.

When will you be able to start work? How did you learn of the Company?
Have you ever applied or worked for the Company before? Yes No
Are you legally authorized to work in the United States? Yes No
Will you now or in the future require sponsorship for employment visa status (e.g.,H-1B visa status)? Yes No

* Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

DRIVING RECORD

(Answer only if driving is a requirement of the job for which you are applying).

Do you have a valid driver's license Yes No State: License No:
Have you had any tickets? Yes No

EDUCATION

Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for:

Highschool

Did you graduate? Yes No
Type of Degree Received or Expected
Major
Minor GPA

College or University

Did you graduate? Yes No
Type of Degree Received or Expected
Major
Minor GPA

Technical/GED

Did you graduate? Yes No
Type of Degree Received or Expected
Major
Minor GPA

Licenses/Certification/Other

Did you graduate? Yes No
Type of Degree Received or Expected
Major
Minor GPA

EMPLOYMENT HISTORY

Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include military assignments and voluntary employment and provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history.

1.

Company Name: Telephone:
Address:
Name of Supervisor: May we contact: Yes No
Dates Employed From: To:
State job title and describe job duties:
Reason for leaving:

2.

Company Name: Telephone:
Address:
Name of Supervisor: May we contact: Yes No
Dates Employed From: To:
State job title and describe job duties:
Reason for leaving:

3.

Company Name: Telephone:
Address:
Name of Supervisor: May we contact: Yes No
Dates Employed From: To:
State job title and describe job duties:
Reason for leaving:

4.

Company Name: Telephone:
Address:
Name of Supervisor: May we contact: Yes No
Dates Employed From: To:
State job title and describe job duties:
Reason for leaving:

PROFESSIONAL REFERENCES

(Please list three individuals unrelated to you with whom you have worked who know your qualifications for this position.).

Name Address:
Phone Relationship:

Name Address:
Phone Relationship:

Name Address:
Phone Relationship:

MILITARY

(Complete only if you served in the military.)

Branch of Service Number of years / Months of service
Rank at Discharge Date of Discharge:
Describe any military skills, training or experience you believe are relevant to the job you applied for:

APPLICANT’S ACKNOWLEDGMENT


I certify that the answers given herein and during the entire application process (including but not limited to information provided in resumes, attachments to this application, interviews or otherwise (if applicable)) are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers during the application process may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice.


I consent to and authorize the Company and ADP TotalSource® to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment. I further authorize the listed employers, schools and personal references to give the Company or ADP TotalSource (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have and hereby waive any actions which I may have against either party(ies) for providing a good faith reference.

I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT IS NOT FOR A SPECIFIC TERM, IS BASED ON MUTUAL CONSENT AND MAY BE TERMINATED BY ME OR THE COMPANY OR ADP TOTALSOURCE WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME. I FURTHER UNDERSTAND THAT NO ORAL PROMISE, EMPLOYER POLICY, CUSTOM, BUSINESS PRACTICE OR OTHER PROCEDURE (INCLUDING THE BASIC EMPLOYMENT POLICIES, PERSONNEL HANDBOOK OR ANY PERSONNEL MANUALS) CONSTITUTES AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT-WILL EMPLOYMENT RELATIONSHIP BETWEEN ME AND THE COMPANY OR ADP TOTALSOURCE.


I ALSO UNDERSTAND THAT MY AT-WILL EMPLOYMENT STATUS WITH THE COMPANY MAY ONLY BE ALTERED IN AN INDIVIDUAL CASE OR GENERALLY IN A WRITING SIGNED BY THE OWNER, PRESIDENT OR CEO OF THE COMPANY AND THAT MY AT-WILL STATUS WITH ADP TOTALSOURCE MAY ONLY BE ALTERED IN AN INDIVIDUAL CASE OR GENERALLY IN A WRITING SIGNED BY THE PRESIDENT OF ADP TOTALSOURCE.


I understand that I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination or take a preemployment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent on a satisfactory result on all required tests. I authorize the Company and ADP TotalSource to release the results of my pre-employment drug/alcohol test (if any),any information on this application and any relevant information about me to each other and to other ADP TotalSource clients for whom I have applied for employment, and release the Company, ADP TotalSource and its clients from any and all claims related to the lawful release of this information. I further authorize the release of any background check results and of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document.


* Date

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