Equal access to programs, services and employment is available to all persons. Those applications requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resource Department.

GENERAL INFORMATION  Position(s) applied for:   Date of Application: Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2007 2008 2009  Name:   Social Security Number:  Street Address:     City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:  Telephone Number:   Mobile Number: E-mail Address:  Referral Source (How did you hear about us?):    If you are 18, and it is required, can you furnish a work permit? Yes No  If no, please explain:    Have you ever been employed here before? Yes No  If yes, give dates and positions:    Are you legally eligible for employment in this country: Yes No  Date available for work:   Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2007 2008 2009 What is your desired salary range? Type of employment desired: Full-Time Part-Time Temporary Seasonal Educational Co-Op  Driver license number if driving may be required in position for which you are applying:   State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY  Answering "yes" to the following questions does not constitute an automatic bar to employment. Factors such as date of the  offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.  Have you ever pled "guilty" or "no contest" to, or been convicted of a crime? No Yes  If yes, please provide date(s) and details:    EMPLOYMENT HISTORY  Name, Address, & Phone # of employer Dates of Employment Hourly Rate/Salary Starting-Final Job Title/ Work Performed Supervisor's Name    From  To  Starting Final    From  To  Starting Final    From  To  Starting Final  SKILLS AND QUALIFICATIONS  Summarize any special training, skills, licenses and/or certificates that may assist you in performing this position:    Additional Skills (Check appropriate boxes. Include software titles and years of experience.)  Fork Lift Operator: Years:    DOT EPA OSHA Training: Years:    Basic Electric/Plumbing: Years:    Welding: Years:    Computer: Years:    Other: Years:    EDUCATIONAL BACKGROUND  Starting with your most recent school attended, provide the following information:  School (Include city and state):   Years Completed: Completed: None Diploma GED Degree Certification Other GPA Major/Minor  School (Include city and state):   Years Completed: Completed: None Diploma GED Degree Certification Other GPA Major/Minor  School (Include city and state):   Years Completed: Completed: None Diploma GED Degree Certification Other GPA Major/Minor  REFERENCES  List name and telephone number of three business/work references who are NOT related to you and are NOT previous  supervisors. If not applicable, list three school or personal references who are NOT related to you.  Name:   Title: Relationship to you: Telephone Number: Years Known:  Name:   Title: Relationship to you: Telephone Number: Years Known:  Name:   Title: Relationship to you: Telephone Number: Years Known:  APPLICANT STATEMENT  I certify that all info I have provided in order to apply for and secure work with this employer is true, complete and correct.  I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain  information from all references (personal and professional), employers, public agencies, licensing authorities and educational  institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job  interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or  representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the  employment process and all other persons, corporations or organizations for furnishing such information about me.  I understand that this employer does not unlawfully discriminate in employment and no question on this application is used  for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by  applicable local, state or federal law.  I understand that this application remains current for only 30 days. At the conclusion of that time, If I have not heard from  the employer and still wish to be considered for employment, I will need to reapply and fill out a new application.  If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and  the employer reserves the right to terminate my employment at any time, with or without cause and with or without prior  notice, except as may be required by law. This application does not constitute an agreement or contract for employment for  any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to  make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express  language are valid unless they are in writing and signed by the employer's president.  I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the  United States and that federal immigration laws require me to complete an I-9 Form in this regard.  I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will  be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate  discharge from the employer's service, whenever it is discovered. BY CLICKING BELOW, YOU FULLY UNDERSTAND AND ACCEPT ALL TERMS OF THE FOREGOING APPLICANT STATEMENT.