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Please check one :

SHAREHOLDER SHAREHOLDER DESCENDANT SHAREHOLDER SPOUSE

Name of spouse or original shareholder:

Please Print

REQUISITION #:___________________ POSITION TITLE:_____________________DATE

Applicant Information

Name:
Last First Middle

Address:

City/State: Zip Code:

Telephone: ( ) E-mail

Do you have a valid driver's license? Yes No State/License #:

Have you ever applied to, or worked for this company before? Yes No If yes, when?

Are you legally eligible for employment in the U.S.A? Yes No (If yes, verification will be required)

General Information About Employment Desired

Position you are applying for? Full-time Part-time Temporary

If part-time, hours per week desired: Are you available for work on weekends?

Are you available to work holidays? Days of week you are available to work:

Hours you are available to work: Are you available to be on-call?

Are you available to work evenings and nights? _________Are you available to work overtime?

If hired, on what date could you start work?

Are you able to travel on company business? % time willing to travel:

If necessary for the job, are you over: 14 15 16 18 19 21 (Please circle one)

Education and Training (Include on-the-job training)

School Name/Location

Yrs. Completed

Field of Study

Graduate or Degree

High School

Community College

Trade School

College/University

Seminars/Other

Military Service ð Yes ð No Duty/Specialized Training

Reference: List two personal references who are not relatives or former supervisors.

Name Address/Phone Occupation Years Known

Employment History: List last employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary (following this section), or use an extra sheet of paper if necessary.

Employer Name and Address

Position Title/Duties Skills:

Date Employed:

/ / / /

From To

Salary:

Reason for Leaving:

Supervisor's Name:

Phone:

( )

Employer Name and Address

Position Title/Duties Skills:

Date Employed:

/ / / /

From To

Salary:

Reason for Leaving:

Supervisor's Name:

Phone:

( )

Employer Name and Address

Position Title/Duties Skills:

Date Employed:

/ / / /

From To

Salary:

Reason for Leaving:

Supervisor's Name:

Phone:

( )

Employer Name and Address

Position Title/Duties Skills:

Date Employed:

/ / / /

From To

Salary:

Reason for Leaving:

Supervisor's Name:

Phone:

( )

Summarize other relevant experience, skills and background:

Computer skills

Dates Used

Level of proficiency

Professional Licenses, Certifications or Registrations:

Additional skills including supervision skills, other languages, or information regarding the

career/occupation you wish to bring to the employer's attention:

In case of emergency, please contact:

Name: Address:

Street City State Zip Code

Daytime Phone Number:( ) Relationship:

Since your 18th birthday, have you been convicted of a felony or felony-reduced-to misdemeanor conviction by any court? You may omit conviction of a misdemeanor while under age 18 if the record was sealed under Penal Code 1203.45, minor traffic violations for which the fine imposed was $400.00 or less, any offense that was finally settled in juvenile court or referred to the youth authority, or any conviction specified in Health and Safety Code Section 11361.5 which pertains to certain marijuana offenses. Please answer Yes No (If YES, date, location and explanation): ___________________________________________________________________

___________________________________________________________________________________________

Have you ever been convicted of a federal crime, as defined in 42 USC 1320a-7(i) or been excluded from participating in any federal or state health care program? Yes No (If YES, date, location and explanation:

___________________________________________________________________________________________

___________________________________________________________________________________________


Information to the applicant: As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references.

If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the US, have a physical examination and/or a drug test, to sign a conflict of interest agreement, or a confidentiality agreement and abide by its terms.

I understand and agree to the information shown above.

Applicant's Signature Date

Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment.

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