PRE-EMPLOYMENT APPLICATIONOur Company is an equal opportunity employer and will consider all applicants for all positions equally without regard totheir race, sex, age, color, religion, national origin, veteran status or any disability as provided in the Americans WithDisabilities Act.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Eachquestion should be answered in a complete and accurate manner as no action can be taken on this application until allquestions have been answered.

PERSONAL: Date _ ____/ _____ / _____

Name _________________________________________________________ Home Phone (______ ) ___________________LAST FIRST MIDDLE AC

Present Address ________________________________________________________________________________________NO. STREET CITY STATE ZIP

Social Security No. __________________________________ Are you over 18? Yes___ No___

Are you a citizen of the U.S. or do you have the legal right to be employed in the United States? Yes___ No___

Have you ever been convicted of any crime {excluding minor traffic violations) including driving while under the influenceof alcohol or drugs? Yes___ No___

If yes, state the offense, location, date and disposition _____________________________________________________

If no, please explain __________________________________________________________________________________

Drivers License: State ________________________Type ___________________ Currently Valid? Yes___ No___

EMPLOYMENT DESIRED:

Are you seeking ___ full-time ___ part-time ___ temporary or summer employment?

Position applied for ___________________________________ Salary Desired_________________

Date Available to start ________________

Have you ever applied to our company before? Yes ___ No___

Have you ever worked for our company before? Yes___ No___

If your answer to either of the above questions is Yes, state when and where you applied and/or worked.

How did you learn of our company and/or position? ________________________________________________________

Are there any days or hours you would be unable or unwilling to work? Yes___ No___ If yes, please specify those days

or hours you would be unable or unwilling to work ____________________________________________________________

NOTE: A conviction will not necessarily disqualify you from employment.

Do you have the ability, with or without reasonable accommodations, to work overtime or to travel if travel and/or overtimeare required by the job for which you are applying? Yes___ No___

TKielTypewritten text________________________________________________________________________________________

TKielTypewritten text________________________________________________________________________________________

EDUCATION:Name, Address and Location Dates Graduate? Courses StudiedHigh School Yes Diploma:

No

College From: Yes Diploma:

To: No

Trade School From: Yes Diploma:

To: No

If you did not graduate, why did you leave high school or college?_____________________________

Are you planning to pursue further studies? Yes___ No___ If so, when, where and what courses? ________________

__________________________________________________________________________________________________

List any scholastic honors, offices held and activities involved in during high school and college _______________________

___________________________________________________________________________________________________

List and describe any other School or Specialized Training ____________________________________________________

___________________________________________________________________________________________________

MILITARY:

Have you ever served in the military? Yes___ No___

Service Branch __________________________________

Date Separated ___________________________________

Date Entered _____________________________________

Final Rank _______________________________________

CAPABILITY / RELIABILITY:

Would you be willing and able to perform all of the tasks required by the job you are applying for? Yes___ No___

If not, explain which tasks ____________________________________________________________________

Have you filed any type of fraudulent claim against any of your present or past employers? Yes___ No___

If yes, explain _____________________________________________________________________________

Will you abide by the safety rules of this company? Yes___ No___

Have you ever been disciplined for violating company safety rules or regulations? Yes___ No___

If yes, please explain __________________________________________________________________________________

WORK HISTORY

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time includingmilitary service and any periods of unemployment. If self-employed, give firm name and supply business references.PLEASE GIVE MONTH AND YEAR. DO NOT REFERENCE YOUR RESUME.

Dates Employed Pay

From:Mo. ___

To:Mo.__

Starting$

Name of EmployerAddressCity, State, Zip Code

Year___ Ending$Telephone With Area Code

( )Nature of Business

Name and Title ofLast Supervisor

Year___

Title

Duties

Reason for Leaving

Dales Employed Pay

FromMo. __

To:Mo.__

Starting$

Name of EmployerAddressCity, State, Zip Code

Year___ Ending$

Telephone With Area Code( )

Nature of Business

Name and Title ofLast Supervisor

Year___

Title

Duties

Reason for Leaving

Dates Employed Pay

FromMo.___

To:Mo.__

Starting$

Name of EmployerAddressCity, State, Zip Code

Year___ Ending$

Telephone With Area Code( )

Nature of Business

Name and Title ofLast Supervisor

Year___

Title Reason for Leaving

Duties

Dates Employed Pay

From:Mo. ___

To:Mo. __

Starting

$

Name of EmployerAddressCity, State, Zip Code

Year__Ending$

Telephone With Area Code( )

Nature of Business

Name and Title ofLast Supervisor

Year____

Title Reason for Leaving

Duties

Echelon Publishing Note:

Echelon Publishing Note:

Echelon Publishing Note:

Echelon Publishing Note:

Echelon Publishing Note:

Echelon Publishing Note:

SUPPLEMENTAL EMPLOYMENT INFORMATIONIf you worked in any of your previous positions under another name, please give that name(s) below: (For reference checking purposes)

Name ______________________ Company ________________________ Name _____________________ @ Company______________Are you presently employed? Yes___ No ___If yes, may we contact your present employer? Yes___ No ___

REFERENCES

Give three references, not relatives or former employers.

Name Address Phone Occupation

AFFIDAVIT

I hereby authorize the Company to contact any company or individual it deems appropriate to investigate my employment history, character andqualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. I also understand thatmy employment is "at-will" and may be terminated by myself or by the company at any time for any reason or no reason at all, with or without priornotice.

COMPANY USE ONLY REFERENCE COMMENT

Interviewed by:

Interviewers remarks:

Job offered:.Yes___No ___

Salary offered:

Start date:

Time already need off:

DRUG SCREENING

Signature___________________________________________________________ Date _____ /_____/______

Signature___________________________________________________________ Date _____ /_____/______

I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if Iam employed, any false, misleading or otherwise incorrect statements made on this application form or during any interviews may be grounds for myimmediate discharge.

I, ________________________________ understand that my employment is contigent upon the results of my pre-employment drug screening, and that a negative test result will prevent my employment with the company.

page_4a.pdfREFERENCESAFFIDAVIT

Name: Date 2: Date 3: Date 1: AC: Ph #: Address: SS#: Offense: Y1: N1: Y2: N2: Y3: N3: Overtime: DL State: DL Type: Y5: N5: FT: PT: Temp: Position: Salary: Date Available: Y6: N6: Y7: N7: Company Learn: Applied For: Y8: N8: Unable: N11: Entered: Safety Explain: N17: Y17: N16: Y16: Claims: Y15: task: N14: Y14: Rank: Separated: Svs Branch: N13: Y13: Training 2: Training 1: Honors 2: Honors 1: Pursue 2: Pursue 1: N12: Y12: Did Not Graduate: Diploma 3: Diploma 2: Diploma 1: Y11: N10: Y10: N9: Y9: T To: T From: C To: C From: HS Date: Trade School: College: High School: RFL3: RFL2: RFL1: E2: A1: ep4: sp4: y4a: m4a: m4: RFL4: Super4: ep3: sp3: y3a: m3a: m3: Super3: y2a: ep2: sp2: m2a: m2: Super2: sp1: ep1: y1a: m1a: m1: Super1: EDuties4: ETitle4: NOB4: ET4a: ET4: C4: A4: E4: EDuties3: NOB3: ET3a: ET3: C3: A3: E3: EDuties2: ETitle2: NOB2: ET2a: ET2: C2: A2: EDuties1: Etitle1: NOB1: ET1a: ET1: C1: E1: r12: r11: r10: r9: r8: r7: r6: r5: r4: r3: r2: r1: 4n2: 4n1: 4y1: 4company2: 4name2: 4company: 4name: N15: 4Y2: y111: y222: ETitle3: y333: y444: