TO APPLICANT: The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits discrimination on th ebasis of age with respect to certain individuals as well as discrimination on the basis of a physical or mental disability. The laws of most States also prohibit some or all of the above types of discrimination as well as some additional types such as discrimination based upon ancestry or marital status.

Please Print or Type neatly all information and Please do not leave any blanks.

Name: _______________________________________________ Date: ________________

Mailing Address:_______________________________________

Physical Address:______________________________________

Telephone Number:____________________________________

Position(s) applied for:_________________________________ Full time____ Part time____

If part time specifiy days/hours___________________ Rate of hourly pay expected $_____

Have you worked for us before? _____ IF YES, which location?_____________When?_____

Indicate special qualifications or skills and educational accomplishments:

MISCELLANEOUS

Are you over 21? _____ (If NO, applicant is subject to minimum legal age verification.)

Have you been convicted of a crime within the past ten years (excluding misdemeanors and traffic offenses)?_____ (Conviction for a felony or misdemeanor will not necessarily be a bar to employment. Factors such as the age and the time of the offense, seriousnessness and nature of the violation, and rehabilitation will be taken into account.)
If YES, list conviction:_________________________________________________________

Can you meet the attendance requirements of the position? ____Yes ____No

Are you a U.S. Citizen? ____Yes ____No

If Not, are you a lawfully immigrated alien who is legally eligible to work? ____Yes ____No