Name

Last: First: Middle/Maiden:

Address:

City: State: Zip:

How long at this address:

Telephone (include area code):

E-Mail address:

If under 18, please list age:

Position(s) for which you would like to apply:

Desired salary:

Employment desired:

FULL-TIME ONLY PART-TIME ONLY FULL- OR PART-TIME

On what date are you available for work?

EDUCATION:

DO YOU HAVE A VALID DRIVER’S LICENSE? Yes No

Have you had any accidents during the past three years? Yes No

How many?

Have you had any moving violations during the past three years? Yes No

How Many?

Please list two professional references below:

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying:

Have you ever served in the Armed Forces? Yes No

Are you currently a member of the National Guard? Yes No

Specialty:

Date Entered:

Discharge Date:

Work Experience

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Name of employer:

Address (include address, city, state and ZIP Code):

Phone Number:

Name of last supervisor:

Employment dates (from start to final):

Pay rate or salary:

Job Title:

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:

Name of employer:

Address (include address, city, state and ZIP Code):

Phone Number:

Name of last supervisor:

Employment dates (from start to final):

Pay rate or salary:

Job Title:

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:

Name of employer:

Address (include address, city, state and ZIP Code):

Phone Number:

Name of last supervisor:

Employment dates (from start to final):

Pay rate or salary:

Job Title:

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:

Name of employer:

Address (include address, city, state and ZIP Code):

Phone Number:

Name of last supervisor:

Employment dates (from start to final):

Pay rate or salary:

Job Title:

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:

Did you complete this application yourself? Yes No

If not, who did?

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Young and Associates (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of , or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.
I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

Checking this box serves as your signature

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.
Thank you for completing this application form and for your interest in our business