First Name, Middle Init.

Last Name

Address

City, State, Zip

Telephone

Cell Phone

E-mail

Have you ever applied for employment with us before?

Yes No
If yes, when?

Position Desired

Desired Salary

Are you eligible to work in the United States?

Yes No

If offered employment, you will be required to provide documentation to verify eligibility

Are you available to work holidays?

Yes No

When can you begin work?

Are you 18 or older?

Yes No

Are you currently on "lay-off" status and subject to recall?

Yes No

Have you ever been convicted of or pleaded no contest to a felony within the past 5 years?

Yes No
If yes, explain?

Have you ever been convicted, plead guilty to, or pleaded no contest to an act of dishonesty, or breach of trust or moral turpitude, such as a misdemeanor petty theft, burglary, fraud, writing bad checks, and other related crimes within the last 5 years.

Yes No
If yes, explain?

Conviction of a crime, or pleading guilty to a criminal charge, will not necessarily disqulify you from the job for which you are applying. Each conviction or plea will be considered with respect to time, job relatedness, and other relavant factotrs.

Employer #1:

Company Name

Job Title

Address

City, State, Zip

Telephone

Name of Supervisor

Employment Dates

May we contact this employer?

Yes No

Reason for leaving

Employer #2:

Company Name

Job Title

Address

City, State, Zip

Telephone

Name of Supervisor

Employment Dates

May we contact this employer?

Yes No

Reason for leaving

Employer #3:

Company Name

Job Title

Address

City, State, Zip

Telephone

Name of Supervisor

Employment Dates

May we contact this employer?

Yes No

Reason for leaving

High School (Name, City, Sate)

Did you graduate?

Yes No

College (Name, City, Sate)

Major/Course of Study

Years Completed

Did you graduate?

Yes No

Degree

Days Avaialable

Sun Mon Tue Wed Thu Fri Sat

Total hours available

Do you have other special training or skills?

Can you perform the essential functions of this job, either with or without reasonable accomodation?

Yes No
Any questions regarding duties?

How did you hear of the organization and position?

Do you have any relatives or friends who work for endagraph?

Yes No
List them below?

First Name, Middle Init.

Last Name

Address

City, State, Zip

Telephone

E-mail

First Name, Middle Init.

Last Name

Address

City, State, Zip

Telephone

E-mail

First Name, Middle Init.

Last Name

Address

City, State, Zip

Telephone

E-mail

I declare the information provided by me in this application is true, and complete to the best of my knowledge. I understand that if employed, any falsification, misstatementm or omission of fact in conncection with my application, whether on this document or not, may result in immediate termination of employment. I authorize you to verify any and all information provided above.

Endagraph, Inc. is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the bais of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.

I acknowledge that employment may be conditional upon successful completion of a substance abuse screening test as part of the company's pre-employment policy.

I acknowledge that if i become employed, I will be free to terminate my employment at any time for any reason, and that Endagraph, Inc. retains the same rights. No Endagraph, Inc reprersentative has the authority to make any contrary agreement.

I acknowledge that by my signature (electronically from this form), I am giving my consent for Endagraph, Inc. representatives to confirm and verify all employment and reference information I have provided, unless I have specified otherwise on this application.

Your full name

Date

Electronic Signature

By selecting yes you are choosing to sign this application electronically. Please initial to verify.

Yes No
Initial below?