PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS
PLEASE COMPLETE PAGES 1-5.						DATE ________________________________
Name __________________________________________________________________________________________
Last First Middle Maiden
Present address __________________________________________________________________________________
Number Street City State Zip
How long ___________________			Social Security No. _______ – _____ – _________
Telephone ( )
If under 18, please list age ____________________
Position applied for (1)_______________________ and salary desired (2) ______________________ (Be specific)				Days/hours available to work No Pref _______ Thur _________ Mon __________ Fri __________ Tue __________ Sat _________ Wed _________ Sun _________
How many hours can you work weekly? _______________________ Can you work nights? _______________________
Employment desired qFULL-TIME ONLY qPART-TIME ONLY qFULL- OR PART-TIME
When available for work?______________
________________________________________________________________________________________________
TYPE OF SCHOOL	NAME OF SCHOOL	LOCATION (Complete mailing address)			NUMBER OF YEARS COMPLETED		MAJOR & DEGREE
High School
College
Bus. or Trade School
Professional School
HAVE YOU EVER BEEN CONVICTED OF A CRIME? q No q Yes
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. _______________________________________________
________________________________________________________________________________________________

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
DO YOU HAVE A DRIVER’S LICENSE? q Yes q No
What is your means of transportation to work? ___________________________________________________________
Driver’s license number ___________________________ State of issue _______ q Operator q Commercial (CDL) qChauffeur
Expiration date ______________________
Have you had any accidents during the past three years?			How many? _________________
Have you had any moving violations during the past three years?			How Many? __________________
	OFFICE ONLY
q Yes q Yes Word q Yes Typing q No _____ WPM 10-key q No Processing q No _____ WPM
Personal q Yes PC q Computer q No Mac q		Other __________________________________________ Skills __________________________________________
Please list two references other than relatives or previous employers.
Name ______________________________________		Name _________________________________________
Position _____________________________________		Position _______________________________________
Company ___________________________________		Company ______________________________________
Address ____________________________________		Address _______________________________________
_____________________________________		_______________________________________
Telephone ( )		Telephone ( )
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
		MILITARY
HAVE YOU EVER BEEN IN THE ARMED FORCES? q Yes q No
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? q Yes q No
Specialty _________________________________ Date Entered ________________ Discharge Date ______________
Work Experience	Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.
Name of employer Address			Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number				From To	Start Final
			Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer Address			Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number				From To	Start Final
			Your Last Job Title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
Work experience	Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.
Name of employer Address		Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number			From To	Start Final
		Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer Address		Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number			From To	Start Final
		Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
May we contact your present employer? q Yes q No
Did you complete this application yourself q Yes q No
If not, who did? ___________________________________________________________________________________

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by American Independent, Inc. (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of American Independent, Inc. or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and American Independent, Inc. may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

Signature of applicant__________________________________________ Date: ___________________

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE
POST EMPLOYMENT INFORMATION FORM
TO BE COMPLETED AFTER EMPLOYEE HAS BEEN HIRED
Height ______ ft. ______ in. Weight __________ Birth date _______________
Married q Yes q No If married, how long? _____ q Single q Separated qDivorced qWidowed
Full name of spouse _______________________________ Occupation _____________________________________
Name of company _________________________________ Telephone ( )
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
Name __________________________________________ Telephone ( )
Address _________________________________________ Relationship ____________________________________
FOR INSURANCE PURPOSES ONLY: LIST ALL DEPENDENTS
NAME	RELATIONSHIP		BIRTH DATE	SSN
		TO BE COMPLETED
		^BY EMPLOYER
Date of employment _________________ Job title ____________________ Dept. ____________________________
Location___________________________ Rate of pay _________________ q Full-time q Part-time q Salaried
Applicant’s signature acknowledging above information ____________________________________________________
Drug test confirmation number ______________________________
Name of person verifying information __________________________________________________________________
Name of person authorizing employment _______________________________________________________________

Applicant Selection Criteria Record

JOB TITLE
CANDIDATES CONSIDERED (INCLUDING MINORITIES AND FEMALES)
NAME		MALE/ FEMALE	ETHNIC CODE*	ON LAB SECTION/ OFF LAB
*ETHNIC CODES: 1-BLACK, 2-ORIENTAL, 3-HISPANIC, 4-AMERICAN INDIAN, 0-OTHER
CANDIDATE SELECTED
NAME		MALE/ FEMALE	ETHNIC CODE		SOURCE
SELECTION CRITERIA
REASONS CANDIDATE SELECTED WAS PREFERABLE TO OTHERS
	ORIGINATOR'S SIGNATURE					DATE