YOUR INFORMATION

EMPLOYMENT INFORMATION

Answering yes does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness, and nature of the violation, rehabilitation and position applied for will be taken into account.

Licensure

Professional Licenses and/or Certifications
Check all that apply.
Please identify licensure and/or certification:

Education

List the school name, address and the course of study where applicable.
List the school name, address and the course of study where applicable.
List the school name, address and the course of study where applicable.

Starting with your most recent employer, provide the following information.

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References

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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 elimination 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 60 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 an assurance 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 1-9 Form in this regard.

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.

VOLUNTARY AFFIRMATIVE ACTION INFORMATION

Completion of the information below is voluntary. In an effort to comply with requirements regarding Affirmative Action record keeping, please complete this applicant data survey. Your cooperation is appreciated. The survey is not part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.
Includes persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish origin or culture regardless of race.

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