Indian Springs Employment Application We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, sexual orientation, disability, or any other protected classification. Personal Information First Name: Middle Name: Last Name: Home Phone: Work Phone: Cell Phone: Email Address: Addresses Street: City: State: Zip Code: Since (Mo/Yr): To (Mo/Yr): Current Address: Prior Address: Prior Address: Education School Attended: City: State: Diploma: Degree/Cert.: Area of Study High School: No Yes GED: Undergrad School: No Yes Grad School: No Yes Other School: No Yes Employment Information Position Applied For: Date You Can Start: Desired Salary: $ Do You Prefer: Full-TimePart-Time Can you work:  Weekends  Evenings Available: M Tu W Th F Sa Su Not Available: Please answer all of the following questions. 1. Are you at least 18 years of age and legally eligible to work for our company in the United States? No Yes 2. Have you worked for this business before? No Yes If yes, please provide dates and locations. 3. Have you received a description of the job or been made aware of the essential functions of the job for which you are applying? No Yes 4. Do you understand the job requirements? No Yes If no, please explain. 5. Are you on layoff and subject to recall? No Yes 6. Are you currently bound by a noncompetition, confidentiality or trade secret agreement? No Yes If yes, please explain... 7. Have you ever been discharged or asked to resign from a job? No Yes If yes, please explain... 8. Have you ever been convicted of or pled guilty to a felony or crime other than a minor traffic citation? No Yes If yes, please explain... Employment History May we contact your present employer? No Yes Please list below your last four employers beginning with the most recent: Most Recent Employer Prior Employer (1) Prior Employer (2) Prior Employer (3) Employer: City: State: Zip Code: Phone: Position Held: From (m/yyyy): To (m/yyyy): Pay Upon Leaving: Supervisor: Duties: Reason For Leaving: Job-related Skills Please answer the following questions if the position you are applying for requires driving a motor vehicle: 1. Do you have a valid driver's license? No Yes If yes, Driver's License Number: Date of Issue: 2. Have you been convicted of or pled guilty to any traffic-related offense within the past five years? No Yes 3. Have you had your driver's license suspended or revoked or had your driving privileges modified by a court of law? No Yes 4. Please list all states from which you hold or held a driver's license: Please use this space to list any special skills you may have that relate to the position applied for: Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted, name of organization, and any other relevant information. References Reference (1) Reference (2) Reference (3) Reference (4) Name: Address: Telephone: Relationship: Years Acquainted: Resume (Text Version) Copy and Paste a text version of your resume here. Upload File Attach a file to your application submission CERTIFICATION AGREEMENT 1. Any misrepresentation or omission of facts in my application form or any attachments to my application form (including any resumes) may result in refusal of employment or if employed, termination from employment. 2. I understand and agree that any person authorized by the Company can at any time request that I submit to a search of my person, purses, packages in my possession, or any locker, desk or files that may be assigned to me. I understand that my refusal to submit to such a search may result in termination. I hereby waive all claims for damages resulting from such examination. 3. I understand and agree that I may be required to take a physical examination, blood, urine, or hair test at Company expense, at any time to determine if I am alcohol or drug free and physically fit for the job I am responsible to perform. Failure to submit to such testing may result in termination. I authorize any physician, including my personal physician, to release any information to the Company which may be necessary to determine my ability to perform my assigned duties. I ALSO UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE AT-WILL, MEANING THAT EITHER PARTY CAN END THE EMPLOYMENT RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON. 4. I further understand that the Company can change wages, benefits and/or working conditions at any time and that I may be required to work overtime or on weekends, depending upon job requirements. 5. I UNDERSTAND THAT THE COMPANY MAY, FROM TIME TO TIME, ESTABLISH RULES, REGULATIONS, POLICIES AND/OR DISCIPLINARY PROCEDURES, SOME OF WHICH MAY BE REDUCED TO WRITING. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO ALL APPLICABLE RULES, REGULATIONS, POLICIES, AND/OR DISCIPLINARY PROCEDURES OF THE COMPANY AND/OR ANY DEPARTMENT THEREOF. I UNDERSTAND THAT THOSE RULES, REGULATIONS, POLICIES AND/OR DISCIPLINARY PROCEDURES ARE NOT INTENDED BY THE COMPANY TO CREATE AN OBLIGATION OR EXPECTATION OF CONTINUED EMPLOYMENT. 6. I UNDERSTAND THAT THIS DOCUMENT IS AN application form FOR EMPLOYMENT AND CONTINUED EMPLOYMENT IS NOT BEING OFFERED. I UNDERSTAND AND AGREE THAT MY EMPLOYMENT, BOTH DURING AND AFTER ANY INTRODUCTORY OR ORIENTATION PERIOD, IS FOR AN INDEFINITE PERIOD, AND THAT NOTHING IN THIS APPLICATION FORM OR ANY OTHER COMPANY DOCUMENT SHALL BE DEEMED TO CREATE ANY CONTRACT OF CONTINUED EMPLOYMENT BETWEEN ME AND THE COMPANY. I FURTHER UNDERSTAND THAT MY EMPLOYMENT CAN BE TERMINATED AT WILL AT ANY TIME BY MYSELF OR THE COMPANY FOR ANY OR NO CAUSE. I UNDERSTAND THAT EMPLOYMENT BEYOND ANY INTRODUCTORY OR ORIENTATION PERIOD OR EMPLOYMENT FOR A NUMBER OF YEARS SHALL NOT RESULT IN ANY HEIGHTENED EXPECTATION OF CONTINUED EMPLOYMENT. I UNDERSTAND AND AGREE THAT ANY STATEMENTS TO THE CONTRARY, WHETHER ORAL OR WRITTEN, ARE EXPRESSLY DISAVOWED AND ARE NOT TO BE RELIED UPON BY ME. I FURTHER UNDERSTAND THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO AN AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING EXCEPT IN A WRITTEN DOCUMENT SIGNED BY THE PRESIDENT OF THE COMPANY. 7. It is my understanding that this application form for employment will only remain active for thirty (30) days following the date of application form. Type Name in Signature Box: Today's Date: 2010-09-07 00:57:51 MST