Job Application

First Name

Middle Name

Last Name

Address

City

State

Postal Code

Cell Phone

Home/Other Phone

Email Address

What position are you applying for?

How did you hear about us?Please list a referral source, as in website, job fair, current employee, school, staffing agency, etc.

If necessary, what's the best time to call you?AMPM

What's the best phone number to use?CellHome/other

Are you under 18?YesNo(Note: If under 18, hire is subject to verification that you are of minimum legal age).

Have you submitted an application here before?YesNo

If yes, give date(s) and position(s):

Have you ever been employed here before?YesNo

If yes, give dates:

Is this application a request for reemployment following an extended military leave of absence from this company?YesNo

If hired, can you present evidence of your identity and legal right to work in this country?YesNo

Date available for work:

What is your desired salary range or hourly rate of pay?

Will you relocate if job requires it?YesNo

Will you travel if job requires it?YesNo

Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?YesNoNeed more information about the job's "essential functions" to respond.This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodations, or whether accommodation is necessary. These issues may be addressed at a later stage, to the extent permitted by law.

Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabitation, and position applied for will be taken into account. NOTE: You are not obigated to disclose juvenile records that have been sealed.

Have you ever pleaded "guilty" or "no contest" to or been convicted of a crime?YesNo

If Yes, please provide date(s) and details:

Employer Info

Employer

Employer Phone

Employer Address

Employer City

Employer State

Employer Postal Code

Supervisor's Name

May we contact for reference?YesNoLater

Starting job title/final job title

Why did you leave?

Summarize the type of work performed and job responsibilities.

What did you like most about your position?

What were the things you liked least about your position?

Upload Resume

No file chosen

Optional. File types accepted: pdf, rtf, doc, docx, pages

Skills and QualificationsSummarize any special training, skills, licenses and/ or certificates that may assist you in performing the position for which you are applying:

Computer SkillsPlease tell us about any computer skills you have, as in, Word Processing, Spreadsheet, Presentation, Email, Internet, etc. List software titles and years of experience.

Educational BackgroundStarting with your most recent school attended, provide the following information.

School (include City and State)

Years Completed

GPA Class Rank

CompletedSpecify if you achieved a Diploma, Degree, GED, Certification, or other.

Major/Minor

Reference 1

Name

Title

Relationship to You

Phone

Email Address

How Long Known

Reference 2

Name

Title

Relationship to You

Phone

Email Address

How Long Known

Reference 3

Name

Title

Relationship to You

Phone

Email Address

How Long Known

We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.

Related Information

To what job-related organizations (professional, trade, etc.) do you belong?

Exclude memberships that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.

List special accomplishments, publications, awards, etc.

Exclude information that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.

In your current or a prior job, have you ever written instructions or directions to be followed by employees or customers?YesNoNot Applicable

If yes, please explain:

Is there any other job-related information you want us to know about you?

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category.

Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature

Date

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(281) 331-4466

OUR MISSION

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(281) 331-4466

OUR MISSION

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