Applicant note: This application form is intended for use in evaluating your qualifications for employment.  This is not an employment contract.  Please answer all appropriate questions completely and accurately.  False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment.  All qualified applicants will receive consideration without discrimination because of sex, marital status, race, age, creed, national origin or the presence of disabilities.  A felony conviction will not necessarily bar an applicant from employment.  Affirmative action hiring may be requested by qualified applicants.  Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment.  After an offer of employment, and prior to reported to work, you are required to submit to a medical review.  Depending on company policy and the needs of the job, your will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.
Date
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
FAX
E-mail
Position seeking?
Date you can start
	Check all that apply
	Full time       Part time        Days        Nights      Weekends     Weekdays
Education
High School
College
Other
Security	List states & counties of residence for the last seven years
Yes   No	Have you used any names or Social Security Numbers other than those on this page?
Yes   No	Have you been convicted of, or served time for a crime in the past seven years? If so, please describe below the incidents, City/State and charges.
Skills
Yes   No	If the job requires, do you have a valid Florida drivers licence? DL#
Yes   No	Have you had any moving violations? Describe:
	List below any skills, licenses or certificates that may be job -related or that you feel would be of value to the company
References	PLEASE NOTE: Your application will not be considered unless every question in this section is answered.  Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical.  Ask for a phone book or call information if you need.
Most recent employer
Yes   No	Are you currently working for this employer?
Yes   No	If yes, may we contact?
Employed from	to     Title:
Duties
Supervisor	Phone #
Salary	Reason for leaving?
Previous employer
Employed from	to     Title:
Duties
Supervisor	Phone #
Salary	Reason for leaving?
Previous employer
Employed from	to     Title:
Duties
Supervisor	Phone #
Salary	Reason for leaving?
References	Include only individuals familiar with your work ability.  Do not include relatives.
Name	Phone# Relationship
Name	Phone# Relationship
Name	Phone# Relationship
Comments
Release	I certify  by the submission of this form that I have read and understand the applicant note on this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.  I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment.  I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but no limited to, criminal history and motor vehicle driving records.  I authorize all persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information.  I also understand that the use of illegal drugs is prohibited during employment.  If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.