THE FOLLOWING INFORMATION WILL BE USED ONLY TO THE EXTENT RELEVANT TO THE QUALIFICATIONS AND POSITION FOR WHICH YOU APPLY.
Select the highest grade completed.
Do you have a high school diploma or GED? Yes No
Did you earn a degree from college? Yes No
If Yes, year awarded:
If Yes, name of college:
Have you ever been convicted of, or pled guilty or "no contest" (nolo contendere) to, a misdemeanor or felony? (do not include minor traffic infractions for which you
never appeared in court, offenses which were dismissed or discharged after completion of successful probation, and convictions or pleas which have been deemed
sealed, annulled, or expunged by law)?
Yes ? No
If Yes, give details concerning the type of crime, the date of the conviction or plea, the penalty imposed, and any other circumstances you deem relevant to a full
understanding of what occurred (attach additional sheets if necessary).
NOTE: Answering "Yes" to this question is not an automatic bar to employment. Factors such as age at the time of the offense, seriousness, and nature of the
violation, relatedness to the job sought, the amount of time which has passed since the event occurred, and evidence of rehabilitation will be taken into account.
However, please be advised that a misstatement or omission in answering this question may be grounds for disciplinary action, including discharge.
Have you been arrested or charged with any misdemeanor or felony not disclosed above for which you are out on bail or free on your own recognizance pending
disposition or trial (again, do not include minor traffic infractions for which no court appearance is necessary)? ?
Yes ? No
If yes, give the date(s) and details of the arrest or charge and any other circumstances you deem relevant to a full understanding of what occurred (attach additional
sheets if necessary).
NOTE: Answering "Yes" to this question is not an automatic bar to employment. We will consider whether the circumstances of the arrest or charge substantially
relate to the circumstances of the particular job sought, and other considerations allowed by law. Again, please be advised that a misstatement or omission in answering
this question may be grounds for disciplinary action, including discharge.
Have you ever been sued in a civil action with regard to the death of or personal injury or intentional damage to any person or to any property? ?
Yes ? No
If yes, give details concerning the nature of the claims and defenses raised by the parties, the outcome of the action (e.g., settlement, jury verdict, or other disposition),
and any other circumstances you deem relevant to a full understanding of what occurred (attach additional sheets if necessary).
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Are you currently engaged in using illegal drugs?
Please list the names, addresses, and phone numbers of five people who are not related to you and who are not former employers:
Understandings and Agreements
I understand that any misrepresentation, falsification or omission of this application shall be sufficient reason for refusal to hire or, if discovered
after employment has begun, dismissal of my employment. I hereby authorize investigation of all matters contained in this application and agree
that if the results of such investigation are not satisfactory, any offer of employment may be withdrawn, or, if applicable, my employment may be
terminated immediately. I agree to conform to and adhere to the rules and regulations governing my employment. Further, I understand and agree
that this application and any other materials I may receive are not intended to be, nor shall be construed to be a contract of employment, and that my
employment and compensation may terminate, with or without cause, and with or without notice, at any time, at the option of either myself or my
In consideration of any offer of employment, I hereby acknowledge, understand and agree that the following will constitute terms and conditions of
any such employment:
Any losses or expenses incurred by my employer, its clientele, or other third parties as a result of my unauthorized actions shall be
immediately reimbursed to my employer on terms that are satisfactory and acceptable to my employer. To the extent permitted by
law, I agree and hereby authorize my employer to reduce my wages for any sums owing by me hereunder.
Security Answer : *
Add the numbers and type in the answer.