AN EQUAL OPPORTUNITY - AFFIRMATIVE ACTION EMPLOYER

Personal Information





Employment Interests

List current and/or previous employers.

Are you willing to relocate
 Yes No
Are you willing to travel
 Yes No

Physical Interests

Some of our jobs have specific physical requirements or limitations. if you are applying for such a position. our employment staff will ask you about any physical limitations or disabilities that could endanger you or your fellow employees if you were to fill this particular position.

Do you have any physical condition which may limit your ability to perform the job?

 YES NO



Education

List personal and professional references who you are not related to

SCHOOL/GED
NAME & LOCATION
#YEARS ATTENDED
DID YOU GRADUATE?
SUBJECTS STUDIED

Grammar School
 Yes No
High School
 Yes No
College
 Yes No
Trade, Business, Correspondence
 Yes No
School
 Yes No

Employment

List below. Beginning with your most recent employment /unemployment for past 7 years
name and address of former employers type of position.




Pre-employment Inquiry Release

Public law 91-508 requires that we advise you that a routine inquiry and drug test may be made which will provide information concerning your character, reputation, personal characteristics, and mode of living. you may obtain a copy of this information upon written request.

I hereby certify that the information if supplied in this application is true, complete, and correct to the best of my knowledge, and I understand that any information I withheld or falsely provided in connection with the forgoing application shall be cause for rejection of this application or termination of employment. I hereby authorize affiliated systems, without liability, to contact prior employers ( present employers if authorized), schools or references I have given and authorize said employers, schools or references to make full response to any inquires by affiliated systems in connection with this application for employment including police records. I agree to observe and abide by all rules, regulations, policies and procedures of affiliated systems. I understand and agree that if employed, my employment with the company will be an �at will� relationship, and my employment may be terminated by me or the company at any time without notice with or without cause. I also understand and agree that the �at will� nature of this relationship cannot be modified except by specific written agreement executed by the undersigned and the president of affiliated systems. I further agree that any and all conditions of my employment, including my compensation and benefits, can be changed or terminated with or without cause or notice at any time by affiliated systems, and that employee handbooks, policy manuals, or other manuals, or other company communications to employees are not to be construed as creating any form of contract or employment agreement between the undersigned and affiliated systems.



I UNDERSTAND, AND AGREE, THAT AS A CONDITION OF EMPLOYMENT I MAY BE REQUIRED TO PASS SCHEDULED PHYSICAL EXAMINATIONS AS THEY RELATE TO MY ABILITY TO DISCHARGE MY DUTIES. I HAVE READ, UNDERSTAND, AND AGREE TO THE FOREGOING PARAGRAPHS.


 I agree to all of the above I will come in and sign