List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. if self-employed, give firm name and supply business references. Note: A job offer may be contingent upon acceptable references from current and former employers.

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required.

I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

It is the policy of this organization to provide equal employment opportunity to all qualified applicants for employment without regard to race, color, religion, national origin, sex, age, veteran status or disability.