HUMDINGERS
Employment Application

Qualified applicatnts are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or disability.
Personal Information
Full Name
SSN
Date of Application
Present Address Address
Street Name

Previous Address

Address
Street Name

How long have you lived at this address years months

Telephone No.
In Case of Emergency, Contact: Phone:
Job Applying For Rate of Pay Expected $. per hour
AVAILABILITY: List hours available to work per week
Check here if available anytime
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
From
 To
 From
 To
 From
 To
 From
 To
 From
 To
 From
 To
 From
 To
Do you have any physical, mental, or medical impairment that would interfere with your ability to perform the essential duties of this job with or without an accommodation: YES NO

If yes, please describe in full. (Refer to position description if necessary)
BACKGROUND  
Are you 18 years of age or older? If No, Date of Birth / /
Have you been convicted of a felony? yes no
Have you been convicted of a any crime, excluding misdemeanors? yes no
Have you ever been convicted of an crime involving violence to another person? yes no
Have you ever been convicted of any crime involving dishonesty? yes no
Are you currently serving probation for any misdemeanor offense? yes no
Have you ever been counseled or disciplined for cash handling violations? yes no
Have you ever been counseled or disciplined for being late or absent from work or school? yes no
If you have answered Yes to any of the above, describe in full:
If you have answered Yes to any of the above, describe in full:

List all Present and Past Employment below, beginning with most recent

Name, Address & Phone # of Company Date From Date To Last Position Held:
Title & Duties		 Starting Pay Rate Ending
Pay Rate		 Name of Supervisor Reason for Leaving
/ / $.
per hour		 $.
per hour
/ / $.
per hour		 $.
per hour
/ / $.
per hour		 $.
per hour
Personal References (Not former employers or relatives)
Name & Address Occupation Phone Number

RECORD OF EDUCATION
School Name & Location Years
Attended		 Last Year
Completed		 Did You
Graduate		 List Diploma
or Degree
High School / YESNO
College / YESNO

IMPORTANT - READ BEFORE SIGNING

I certify that information given herein is true and complete to the best of my knowledge.
I authorize investigation of all statements and references contained in this employment application as may be necessary in arriving at an employment decision, including requests for criminal, credit, or motor vehicle driving reports. I understand that incorect, misleading or incomplete information on this application may result in immediate termination of employment. I understand that this employment application and any other company documents are not contracts of employment and that any individual who is hired may voluntarily leave employment upon prior notice and may be terminated by the employer at any time and for any reason. I also understand that any oral or written statements to the contrary are expressly disavowed and should not be relied upon by any prospective or existing employee. I 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 during employment.
I agree to the above terms