Name *

First Name

Last Name

Phone

(###)

###

####

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have a valid drivers license?

Yes

No

U.S. Armed Forces Service?

Yes

No

Are you able to do the job(s) for which you are applying?

Yes

No

Are you able to lift 50 lbs?

Yes

No

Are you 18 years of age or older?

Yes

No

Are you a smoker?

Yes

No

Have you ever been convicted of a felony?

Yes

No

Are there any felony charges pending against you now?

Yes

No

Are you authorized to work in the United States? *

Yes

No

If selected for employment are you will to submit to a pre-employment drug screening test?

Yes

No

Please Read Carefully *

1. Certification of Truthfulness. I certify that all statements on this Application for Employment are made truthfully and without evasion, and further understand and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed, or if employed may result in my dismissal. 2. Authorization for Employment / Educational Information. I authorize the references listed in this Application for Employment, and any prior employer, educational institution, or any other persons or organizations to give this Company any and all information concerning my previous employment / educational accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I hereby waive written notice that employment information is being provided by any person or organization. 3. Employment at Will. If I am hired, in consideration of my employment, I agree to abide by the rules and policies of this Company, including any changes made from time to time, and agree that my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either the Company or myself. I understand that no manager or other representative of the Company, other than the President, has any authority to enter into any agreement for employment for any specific or indefinite period of time, or to make any agreement contrary to the foregoing. Any such agreement made by the President must be made in writing to be effective. 4. Authorization to Work. If I am selected for hire I will be offered employment provided I verify that I am authorized to work as required by the Immigration Reform and Control Act of 1986. 5. Limitation on Claims. I agree that any action or suit against the Company arising out of my employment or termination of employment, including but not limited to claims arising under State or Federal civil rights statutes, must be brought within the time limit specified by Statute or one (1) year of the event giving rise to the claim, whichever is less, or be forever barred. I waive any statute of limitations which exceeds one (1) year. 6. Need for Accommodation. If I am a handicapper who requires an accommodation to perform the job, I must notify the Company of that need within 182 days after I knew or reasonably should have known that an accommodation was needed. Failure to do so will bar me from alleging that the Company has not accommodated me as required by law. 7. Criminal Records Check. I agree to execute an authorization for the Company to secure my criminal conviction history from the appropriate law enforcement agency, should the Company determine it is necessary to do so. 8. Driving Record Check. I agree to execute an authorization for this employer to inquire into, and obtain documents related to, any driving record from every state in which I have held a motor vehicle operator’s license or permit. 9. Release of Medical Information. I authorize every medical doctor, physician or other health care provider to provide any and all information, including but not limited to, all medical reports, laboratory reports, X-rays or clinical abstracts relating to my previous health history or employment in connection with any examination, consultation, test or evaluation. I hereby release every medical doctor, health care professional and every other person, firm, officer, corporation, association, organization or institution which shall comply with the authorization or request made in this respect from any and all liability. I understand that this release will not be sent to my physician or other health care provider until a conditional job offer has been made. 10. Physical Exam and Drug and Alcohol Testing. I agree to take a physical exam following a conditional job offer. I also authorize the Company or its designated agent(s) to withdraw specimen(s) of my blood, urine or hair for chemical analysis. One purpose of this analysis is to determine or exclude the presence of alcohol, drugs or other substances. I understand that decisions concerning my employment may be made as a result of this test. 11. Consideration for Employment. I understand that my application will be considered pursuant to the Company’s normal procedures for a period of thirty (30) days. If I am still interested in employment thereafter, I must reapply.

I have read and understand items 1 through 11 above, and acknowledge that by checking this box. I agree that if any of the above commitments is ever found to be legally unenforceable as written, the particular commitment concerned shall be limited to allow its enforcement as far as legally possible.

I understand that the Company will request a consumer report or an investigative consumer report, including information as to my character, general reputation, personal characteristics and mode of living for general purposes of evaluating my application for employment. I further understand that I may request in writing from the Company a complete and accurate disclosure of the nature and scope of the investigation requested. I consent to the furnishing of such report to the Company. *

I AGREE