Employment Application APPLICATION FOR PART TIME EMPLOYMENT OR CONTRACTUAL ARRANGEMENT Phone Personal Information Name Home Address Home/Cell Telephone Work Telephone Email Address Background Information Are you a United States citizen? (If NO, enter citizenship here.) fld_488035 YES NO If No, are you legally authorized to work in the U.S.? fld_2542183 YES NO Have you ever been convicted of a felony or a first degree misdemeanor? (If YES, explain on the reverse side) fld_8970156 YES NO A complete background check may be performed upon accepting a position or contractual agreement with us. Do you consent to a background check should your application for employment be accepted? fld_96623 YES NO Emergency Contact Name, Relationship and Telephone Number References 2 names & telephone numbers (no family please) Employment History Current Job: Still There? YES NO Describe Responsibilities: Previous Job: Still There? YES NO Describe Responsibilities: Education High School College or Advanced Degree Restrictions Any restrictions? (If any, please indicate on reverse side of this application). fld_3629826 YES NO Are there any days or shifts you are unable to work? fld_2952765 YES NO Do you have transportation available to you? fld_6212217 YES NO Are you able to work weekends and evenings? fld_6371056 YES NO Do you require any special assistance or equipment? fld_3585926 YES NO Any restrictions on use of a computer, mouse, keyboard or the internet? fld_4573750 YES NO Rate YOUR Spelling and Grammatical skills (0 -5) with 0 = Low through 5 = High Rate YOUR Computer skills (0 -‐ 5) with 0 = Low Through 5 = High Drivers License State Classification Restrictions Drivers License Number Signature: Application Date: Statement -‐ I hereby certify that the facts set forth in this application are true and complete. False Statements may be cause for employee termination. References will be checked.