PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION HISTORY

GENERAL INFORMATION

FORMER EMPLOYERS

List below last four employers, starting with last one first

REFERENCES

Give below the names of the three persons, not related to you, whom you have know at least one year. Please include name, contact information, business, and years known

AUTHORIZATION

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from ultilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by and authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."