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Application for Employment
P.O. Box 2820 • Augusta, GA 30914-2820 • (706) 737-4120 (Phone) • (706) 738-8835 (Fax)
Last Name First Name Middle Name
Address City State ZIP
Telephone Email Social Security Number

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Applications are received and employees are hired without regard to race, creed, color, sex, religion, age, national orgin, marital status, physical or mental handicap, disability, sexual orientation, veteran's status, citizenship status, or any other protected classes under state, local, or country regulations. The receipt of this application does not mean that job openings exist and does not obligate us in any way. We appreciate your interest in our organization.

This application will be considered for ninety (90) days.

ALL QUESTIONS MUST BE ANSWERED.

STATE "N/A" IF QUESTION IS NOT APPLICABLE.

THIS IS A DRUG FREE WORKPLACE

This employer reserves the right to terminate an employee at-will, at any time, with or without advance notice to the employee. The employee has the right to terminate employment with the employer at any time without advance notice. Nothing shall be construed or interpreted to constitute a contract of employment.

Personal Information
Date of Application Position(s) Applied For
Salary Expectation On what date would you be available for work?
Are you available to work:
Full Time Part Time Weekend Temporary
Times available for work
  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
From
To
How were you referred to us?
Have you filed an application here before? If yes, give date and location
Yes No
Have you ever been employed here before? If yes, give date and location
Yes No
Are you employed right now? May we contact your present employer?
Yes No Yes No
Does your employer know of your plans to change employment?
Yes No
Why do you desire to make a change?
Are you on layoff and subject to recall?
Yes No
Have you ever been discharged or requested to resign from a position? If yes, explain
Yes No
How much time have you lost from work during the last 12 months?
Do you have steady transporation to work? Can you travel if a job requires it?
Yes No Yes No
Have you ever held a position of trust (handling money or confidential material)?
Yes No
Have you ever been refused bond? If yes, explain
Yes No
Are you legally eligible to work in the United States? (Proof of citenzenship/immegration status and itentity is required upon employment.)
Yes No

Have you ever been convicted of or received a sentence for a crime(s) other than a minor traffic violation?

(Answering "Yes" is not an automatic bar to employment)

 If so, state date, court and place where offense(s) occurred
Yes No
Do you hold a valid driver's license? If so, list State
Yes No
Have you been convicted of any moving violation(s) in the last 3 years? If Yes, give date(s) and explanation
Yes No
List three things that are important to you List three characteristics that best describe you
1) 1)
2) 2)
3) 3)
Why do you want to work here?
Full Employment History (Must be completed even when accompanied by resume)

Start with your present or last job. Include ALL assignments and postions held. Be specific about information and dates.

A COMPLETE WORK HISTORY MUST BE PROVIDED. ALL EMPLOYMENT "GAPS" MUST BE LISTED.

Employer Dates Employed Summary of Work Performed and Job Responsibilities
From (Mo/Yr) To (Mo/Yr)
Address (Street, City and State)
Phone
Job Title Hourly Rate/Salary
Starting Ending
Supervisor
Resigned Terminated, State Reason
If you need additional space to provide a full work history, use the text area below.
Special Skills and Qualifications
Summarize special skills and qualifications aquired from employment or other experience
List professional, trade, business or civic activities and offices held
Computer skills (list programs and profeciency level)
Typing WPM Shorthand WPM
What foreign languages do you speak, read and/or write?
Education Information
SCHOOLING YEARS COMPLETED DEGREE REC. & MAJOR SUB. NAME OF SCHOOL LOCATION DID YOU GRADUATE?
GRAMMAR OR HIGH SCHOOL
TRADE BUS. OR CORRESPONDENCE
COLLEGE
GRADUATE SCHOOL
Honors Received
Military Service
Branch of Service and Serial Number Present Selective Service Classification Rank as Discharge
List Duties / Special Training

If you currently have a resume, you can upload it below. (OPTIONAL)

Agreement

The facts set forth above in my application for employment are true and complete. I understand that false statements or omission of information on this application or any other employment form may lead to dismissal or denial of employment. You are hereby authorized to make any investigation of my personal history, financial, criminal, credit andmotor vehicle records through any investigative or credit agencies or bureaus of your choice. You are also authorized to administer personality profile tests and verify my background. A criminal record or sentence is not an automatic disqualification for employment. I agree to submit to any drug or alcohol testing prior to or after employment and I agree to submit to a medical evaluation, if required.

In making this application for employment, I also understand that an an investigative consumer report may be made whereby information is obtained through personal interviews with my neighbors, friends or others with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics and made of living. I understand that I have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigative consumer report. In exchange for the consideration of my employment application by this company, I hereby release and forever discharge the company (including its directors, officers, employees and agents) and my past and/or present employers (their directors, officers, employees and agents) from any liabilities which may result from an investigation of my past and/or present employment or from the disclosure of such information. I authorize the use of any information in this application to verify my statements, and I authorize the past employers, doctors, all references and any other persons to answer all questions asked concerning my ability, character, reputation and previous employment record.

I understand that if my application is accepted that employment with this company at all times is employment "at will." It is further understood that this "at will" relationship may not be changed by any written docuement, verbal statements, or by conduct unless such change is specifically acknowledged by an authorized executive of the company. I further understand that my "at will" employment may be terminated at any time by myself or the company and includes no guarantee, contract or promise of employment for any specific length of time. I understand that the first ninety (90) days of employment is a new hire introductory period.

Signature of Applicant (type your name) Date
07-29-10
In case of emergency, I authorize you to notify:
Work Phone Home Phone

Ensure all of the above information is filled in and correct and then press the button below to submit your application.