Employment History
List below your last three employers (if applicable): Should cover at least five years starting with most recent.
Employer 1:	Name/Address of Present or Last Employer: Dates of Employment: Job Title: Name/Title of Supervisor: Description of Work: Reason(s) for Leaving: Hourly Wage: May we contact employer/supervisor? Yes   No Phone #
Employer 2:	Name/Address of Present or Last Employer: Dates of Employment: Job Title: Name/Title of Supervisor: Description of Work: Reason(s) for Leaving: Hourly Wage: May we contact employer/supervisor? Yes   No Phone #
Employer 3:	Name/Address of Present or Last Employer: Dates of Employment: Job Title: Name/Title of Supervisor: Description of Work: Reason(s) for Leaving: Hourly Wage: May we contact employer/supervisor? Yes   No Phone #
References
Give below the names of three persons not related to you, whom you have known at least one year.
Name Address Phone Years Acquainted 1. 1 Year 2 Years 3 Years 4 Years 5 Years Over 5 Years 2. 1 Year 2 Years 3 Years 4 Years 5 Years Over 5 Years 3. 1 Year 2 Years 3 Years 4 Years 5 Years Over 5 Years
Miscellaneous
Are you at least 18 years old?* Yes No
Are you legally eligible to work in the United States?* Yes No
Have you been convicted of a felony or misdemeanor in the last 5 years?* Yes No If yes, please describe:
Have you been convicted of a felony or misdemeanor prior to the last 5 years?* Yes No If yes, please describe:

* Federal and State laws prohibit age discrimination. ** Federal law, 8 USC S1324, requires that upon hire you produce proof that you are a U.S. citizen or are otherwise authorized by the U.S. Immigration and Naturalization Service to work in the United States. *** A conviction record will not necessarily be a bar to employment. THIS IS A DRUG AND ALCOHOL FREE ENVIRONMENT PRE-EMPLOYMENT DRUG AND ALCOHOL TESTING IS MANDATORY

* = Required fields