(* indicates required field)
Canada ------------- Afghanistan
Antigua and Barbuda
Bolivia, Plurinational State of
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Cocos (Keeling) Islands
Congo, The Democratic Republic of the
Falkland Islands (Malvinas)
French Southern Territories
Heard Island and McDonald Islands
Holy See (Vatican City State)
Iran, Islamic Republic of
Isle of Man
Korea, Democratic People's Republic of
Korea, Republic of
Lao People's Democratic Republic
Macedonia, Republic of
Micronesia, Federated States of
Moldova, Republic of
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Sint Maarten (Dutch part)
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syrian Arab Republic
Tanzania, United Republic of
Trinidad and Tobago
Turks and Caicos Islands
United Arab Emirates
United States Minor Outlying Islands
Venezuela, Bolivarian Republic of
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Armed Forces Africa, Canada, Europe, Middle East
Armed Forces Americas (except Canada)
Armed Forces Pacific
District of Columbia
Northern Mariana Islands
United States Minor Outlying Islands
Please attach the following files
Please upload either a word or PDF version of your cover letter for this position.
Please upload either a word or PDF version of your current resume.
Any Additional Files:
Such as letters of recommendation, work examples, etc.
Please answer the following questions to help us better evaluate your application.
List any other names (such as former names, aliases and nicknames) that you have used since high school to enable us to verify your work and education record
List any prior places of residence (list all during the past seven years). Include city, state, and months/years lived there:
Can you accept a position immediately? *
If not, what date can you start?
If hired, can you furnish proof that you are at least 21 years of age? *
If hired, are you authorized to work in the United States? *
Do you have friends or relatives working here? *
If yes, please list their name(s) and your relationship:
If a driver license is required for the position for which you are applying, do you have a valid drivers license?
State drivers license issued:
Drivers license no.:
Drivers license expiration date:
Do you have a motorcycle license?
Please list the following information about your high school:
-School name -Years completed -Diploma/Degree -Describe course of study or major
Please list the following information about college:
-School name -Years completed -Diploma/Degree -Describe course of study or major
Describe any specialized training, skills, and extra-curricular activities you participate in.
Have you worked for this Company or any other affiliate of this Company before? If Yes, please include with your employment history below. *
List the names of your previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including military service
and any period of unemployment. If self-employed, list firm’s name and business references. *
Have you ever been terminated or asked to resign from any job? *
If yes, please explain.
Please explain fully any gaps in your employment history: (Do not list any criminal history or medical information such as disability,
illness or pregnancy in response to this question)
If laid off, please give reason.
May we contact your current employer? *
If no, please explain.
Please list 4 professional references. Include name, occupation, address (city, state and zip), telephone number and years known.
Remarks and special qualifications. Please include computer systems and programs with which you are familiar.
Application Statement and Agreement
In the event of my employment to a position in this Company, I will comply with all rules and regulations of this Company. I understand that the Company reserves the right to require me to submit to a test for the presence of drugs in my system prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent upon the passing of a physical examination. Further, I understand that at any time after I am
hired, the Company may require me to submit to an alcohol test, to the extent permitted by law. I consent to the disclosure of the results of any physical examination and related tests to the Company. I also understand that I may be required to take other tests such as personality and honesty tests, prior to employment and during my employment. I understand that should I decline to sign this consent or decline to take any of the above tests, my application for employment may be rejected or my employment may be terminated. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after hiring and a bond application will have to be completed. I hereby authorize the Company with which I have applied for employment to share my Application for Employment with other affiliated companies/employers, and hereby agree that all terms, conditions and/or agreements contained in this Applicant’s Statement and Agreement, or any other documents pertaining to my application for employment, shall be enforceable by me and by such other companies/employers (including their managers, employees and agents), even though I have not signed a separate Applicant’s Statement and Agreement for those other companies/employers. By signing below, I acknowledge that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights or claims I have or may have against my former employers, their agents, employees and representatives, as well as other individuals who release information to the Company, and release them from any and all liability, claims, or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I authorize the persons named herein as personal references to provide the Company with any pertinent information they may have regarding myself. I further understand that as a condition of employment, I may be required to complete additional documentation which would permit the Company and its designated Investigative Consumer Reporting Agency to conduct an investigation of my background, which may include inquiry into my past employment, education, and activities, including, but not limited to, credit, criminal background information and driving record. I also acknowledge that the Company utilizes a system of alternative dispute resolution which involves binding arbitration to resolve all disputes which may arise out of the employment context. Because of the mutual benefits (such as reduced expense and increased efficiency) which private binding arbitration can provide both the Company and myself, I and the Company both agree that any claim, dispute, and/or controversy that either party may have against one another (including, but not limited to, any claims of discrimination and harassment, whether they be based on the applicable state laws, regulations or rules; and/or Title VII of the Civil Rights Act of 1964, as amended, as well as all other applicable state or federal laws or regulations) which would otherwise require or allow resort to any court or other governmental dispute resolution forum between myself and the Company (or its owners, directors, officers, managers, employees, agents, and parties affiliated with its employee benefit and health plans) arising from, related to, or having any relationship or connection whatsoever with my seeking employment with, employment by, or other association with the Company, whether based on tort, contract, statutory, or equitable law, or otherwise, with the sole exception of claims arising under the National Labor Relations Act which are brought before the National Labor Relations Board, claims for medical and disability benefits under the provisions of the applicable state workers’ compensation law, before the applicable state Worker's Compensation Commission and claims for unemployment compensation pursuant to the state specific Department of Employment and Workforce Laws, regulations or rules shall be submitted to and determined exclusively by binding arbitration, I understand and agree that nothing in this agreement shall be construed so as to preclude me from filing any administrative charge with, or from participating in any investigation of a charge conducted by the applicable state's Human Affairs Commission and/or the Equal Employment Opportunity Commission; however, after I exhaust such administrative process/investigation, I understand and agree that I must pursue any such claims through this binding arbitration procedure. I acknowledge that the Company’s business and the nature of my employment in that business affect interstate commerce. I agree that the arbitration and this Agreement shall be controlled by the Federal Arbitration Act, 9 U.S.C. section 1, et. seq., in conformity with the procedures of the applicable state's Rules of Civil Procedure (including all mandatory and permissive rights to discovery) provided that said rules do not contradict the Federal Arbitration Act. However, in addition to requirements imposed by law, any arbitrator herein shall be a retired trial court judge and shall be subject to disqualification on the same grounds as would apply to a judge of a state court. To the extent applicable in civil actions in state courts, the following shall apply and be observed: all rules of pleading (including the right of demurrer), all rules of evidence, and all rights to resolution of the dispute by means of motions for summary judgment, judgment on the pleadings. The arbitrator shall be vested with authority to determine any and all issues pertaining to the dispute/claim raised and such determinations shall be based solely upon the law governing the claims and defenses pleaded, and the arbitrator may not invoke any basis (including, but not limited to, notions of “just cause”) other than such controlling law. The arbitrator shall have the immunity of a judicial officer from civil liability when acting in the capacity of an arbitrator, which immunity supplements any other existing immunity. Likewise, all communications during or in connection with the arbitration proceedings are privileged as though in connection with a state court civil litigation proceeding. The arbitrator shall modify the times set by the rules of civil procedure for the giving of notices and setting hearings. Awards shall include the arbitrator’s written reasoned opinion. The allocation of costs and arbitrator fees shall be governed by statute or controlling case law. Both the Company and I agree that any arbitration proceeding must move forward under the Federal Arbitration Act (9 U.S.C. §§ 3-4) even though the claims may also involve or relate to parties who are not parties to the arbitration agreement and/or claims that are not subject to arbitration: thus, a court may not refuse to enforce this arbitration agreement and may not stay the arbitration proceeding despite any state law provision to the contrary. I UNDERSTAND BY AGREEING TO THIS BINDING ARBITRATION PROVISION, BOTH I AND THE COMPANY GIVE UP OUR RIGHTS TO TRIAL BY JURY. I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. If hired, I agree as follows: My employment and compensation are terminable at will, are for no definite period, and my employment and compensation may be terminated by the Company (employer) at any time and for any reason whatsoever, with or without good cause at the option of either the Company or myself. Consequently, all terms and conditions of my employment, with the exception of the arbitration agreement, may be changed or withdrawn at Company’s unrestricted option at any time, with or without good cause. No implied, oral or written agreements contrary to the express language of this agreement are valid unless they are in writing and signed by the President of the Company (or majority owner or owners if Company is not a corporation). No supervisor or representative of the Company, other than the President of the Company (or major owner or owners if Company is not a corporation), has any authority to make any agreements contrary to the foregoing. This agreement is the entire agreement between the Company and the employee regarding the rights of the Company or employee to terminate employment with or without good cause and this agreement takes the place of all prior and contemporaneous agreements, representations, and understandings of the employee and the Company. Should any term or provision, or portion thereof, be declared void or unenforceable it shall be severed and the remainder of this agreement shall be enforced. If you have any questions regarding this statement, please ask a Company representative before signing. I hereby acknowledge that I have read the above statements and understand the same. *
I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. *
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