E D U C A T I O N	School	Name and Location	Course of study	# Of Years Completed	Did You Graduate?
	Graduate				Yes No
	College				Yes No
	Business/ Trade/ Technical				Yes No
	High School				Yes No

Membership in Professional or Civic Organizations

Please exclude those which may disclose your race, color, religion, or national origin.

EMPLOYMENT HISTORY
1	Company Name	Business Telephone
	Address	Employed from (month/year)
	Name of Supervisor	Weekly Pay
	State your job title and describe your responsibilities	Reason for leaving

2	Company Name	Business Telephone
	Address	Employed from (month/year)
	Name of Supervisor	Weekly Pay
	State your job title and describe your responsibilities	Reason for leaving

3	Company Name	Business Telephone
	Address	Employed from (month/year)
	Name of Supervisor	Weekly Pay
	State your job title and describe your responsibilities	Reason for leaving

4	Company Name	Business Telephone
	Address	Employed from (month/year)
	Name of Supervisor	Weekly Pay
	State your job title and describe your responsibilities	Reason for leaving

We may contact the employers listed above unless you indicate those you do not wish us to contact	DO NOT CONTACT
	Employers Name(s) Reason

MILITARY

Did you serve in the US Armed Forces? Yes No     What branch?

Please describe any training received relevant to the position for which you are applying

Additional Information

The information requested is needed for a legally permissible reason, including, without limitation, national security considerations, a legitimate occupational qualification or business necessity. The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex, or national origin. Federal law also prohibits discrimination based on age, citizenship and disability. The laws of most States also prohibit some or all of the above types of discrimination as well as some additional types such as discrimination based upon ancestry, marital status and sexual preference.

Have you ever been bonded? Yes No  If yes, with what employers?

Have you been convicted of a crime within the past 10 years, excluding misdemeanors and summary offense, which has not been annulled, expunged, or sealed by the court? Yes No If yes, please describe in full detail

What are your goals for the future?

By submitting this document I agree that the information I am providing is true, correct, and complete. If employed any misrepresentation or omission in fact on this application may result in my dismissal. Please initial in the box

I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. Please initial in the box

Please type your full name in this box to confirm the submittal of this application *