Items with * must be filled out or answered in order to finish the application.

Are you currently excluded, suspended, debarred or otherwise or ineligible to participate in federal healthcare programs?

List complete employment history; 1.) begin with current or most recent position; 2.) include military experience which may relate to position for which you are applying; 3.) include all positions, regardless of their relation to the position for which you are applying; 4.) include position held for past seven (7) years only.

Employment Dates:

Salary Per Hour:

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Employment Dates:

Salary Per Hour:

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Employment Dates

Salary Per Hour

List three (not relatives)

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I understand that completing the application does not constitute an offer of employment and that my application may be rejected for any reason; the giving of false or misleading information in this form, during an interview, or during any other portion of the pre-employment process is grounds for denial or immediate termination of employment, that the company will complete a job and a criminal history reference; that i will be required to undergo a Tuberculin Test and maybe required to complete a medical history form and may also be required to be examined by a medical professional designated by the company; that if I sustain any injury or illness while on duty and in the employment of this organization; I agree that this organization shall be entitled to receive full and complete reports and records covering any medical or related examinations, and I authorize any and all such doctors, medical examiners, and hospitals to give this organization full and complete reports and records covering such examinations, condition, care and treatment related to or resulting from the alleged injury or illness that the use of controlled substances, or illegal drugs is prohibited during employment. Likewise working under the influence of alcohol is prohibited. If employment policy required, I am willing to submit to a drug and alcohol testing to detect the use of illegal drugs or alcohol prior to, and during employment.

I authorize the investigation of all statements contained in the application, including but not limited to my past employment history, medical history, scholastic record, criminal activity, federal health care eligibility, motor vehicle driving record, and worker's compensation history. I authorize all persons and organizations to release any information concerning my background and hereby release all persons and organizations from liability fro any damage whatsoever for issuing this information. I understand that misinformation stated on this employment application or given during the interview process is sufficient for the rescinding of a conditional offer of employment, or termination of employment if I am, in fact, employed by the organization.

I understand that nothing contained in this employment application or in the granting of an interview or in any policies, procedures, or handbooks that might I receive is intended to create and employment contract between the company and myself for either employment or for the providing of any benefit. If an employment relationship is established, I understand that I have the right to terminated any employment with due notice at any time, and for any other reasons, and the company retains the right to terminated the employment relationship at any time and for any reason. I understand that any oral or written statements to the contrary are expressly disavowed unless they are writing from the Chief Executive Officer of the Company.