Date of Application:__________

Location applying for:__________

Name: First:____________  Middle:____________  Last:_____________________

Address:_____________________________________________________________

City__________________  State:________  Zip Code:_______________________

Telephone:_________________

Social Security #______/_______/________

Have you ever been employed before? : ______ if yes give dates______________

If under 18 years can you furnish a work permit?_______________

Are you employed now?_______

May we contact your present employ?__________

Are you prevented from lawfully becoming employed in this Country because of
Visa or Immigration Status?___________

On what date are you available to start work? ____________

Are you available to work:
Full-time_______ Part-time________ Shift-work_______ Temp ______

Have you ever been convicted of a felony? ________  A conviction does not
necessarily disqualify an applicant.  If you have been convicted please explain:
____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Are you a Veteran of the U.S. Military? __________
if yes, what branch___________________________

Please put hours you are available for:

EMPLOYMENT EXPERIENCE
(Give most recent experience first)

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

EDUCATION

Elementery:(circle)    4     5     6     7     8   

High School:(circle)     9     10     11     12

College: (circle)     1 yrs     2yrs     3yrs     4yrs    

MAJOR:_______________________________    

DIPLOMA/DEGREE: ______________________  

Please state any additional information you feel may be helpful in considering your application.

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

References (other than family) give name and phone number

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Do you have any medical problems that could effect the performance of your job?  If yes, please explain:

____________________________________________________________________ ____________________________________________________________________
____________________________________________________________________ ____________________________________________________________________

Applicant's Statement

I certify that the answers given are true and complete to the best of my knowledge.  I authorize investigation of all statements contained in this application for employment and this application constitutes an employment contract unless a specific document to that effect is executed in writing.
 In the event of employment,  I understand,  also,  that I am required to abide by all the rules and regulations of the employer.

Signature of Applicant______________________________________DATE:_______________

2001