6. Who referred you to our company? _____________________________________
Do you have any friends or relatives who work here? If yes, please list here:
___________________________________________________________
7. Have you applied to our company previously?______ Yes ______ No
If yes, when? ________________________
8. Are you at least 18 years old?______ Yes ______ No
9. Are you willing to work any shift, including nights and weekends? _____ Yes _____ No
If no, please state any limitations:
________________________________________________
10. If applicable, are you available to work overtime? _____ Yes _____ No
11. If you are offered employment, when would you be available to begin work?
____________________________________
12. If hired, are you able to submit proof that you are legally eligible for
employment in the United States? _____ Yes _____ No
13. Are you able to perform the essential functions of the job position you seek with
or without reasonable accommodation?______ Yes ______ No
What reasonable accommodation, if any, would you request?
________________________________________________
14. Have you ever been convicted of a felony or misdemeanor?
______ Yes, I was convicted of ______________________________ on ____________
(date) in _________________ (city), _______________ (state)
______ No
THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC
BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.