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Medical and Dental Insurance Paid Time off and Paid Holidays 403b Savings Plan
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Employment Application

PERSONAL INFORMATION
Last Name: First Name:    
   
Present Address: City: State: Zip Code:
Permanent Address: City: State: Zip Code:
Telephone #: Email Address: Referred By:  
 
EMPLOYMENT DESIRED
Position: Date you can start: Salary Desired:
Are you employed? Yes  No  
If so, may we inquiry of your present employer? Yes  No  
    If so, when?
Ever applied to this company before? Yes  No
EDUCATION HISTORY
  Name and Location
of School:		 Years Attended: Did you
graduate?		 Subjects Studied:
Grammar School: Yes  No
High School: Yes  No
College: Yes  No
Trade, Business or Correspondence School: Yes  No
GENERAL INFORMATION
Subjects of special study/research work or special training/skills:
U.S. Military or Naval Service:   Rank:  
   
FORMER EMPLOYERS
From - To: Name & Address of Employer: Salary: Position: Reason for Leaving:
REFERENCES (GIVE THE NAME OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR)
Name: Address: Business: Years Known:
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that my result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to this foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
 
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