Application For Employment Equal Opportunity Employer PERSONAL INFORMATION * - Denotes required fields * First Name: Middle Initial: * Last Name: * Address: * City: * State: AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY * Zip: * Phone: Alternate Phone: Email: * Are you 18 years of age or older? Yes No * If hired, can you provide written evidence that you are authorized to work in the U.S.? Yes No EDUCATION Type Name/Location Course of Study # Years Completed Degree/Diploma Elementary/ Junior High High School College Technical/Other EMPLOYMENT RECORD Current or Most Recent Employer - Company Name Current or Most Recent Employer - Address, City, Zip Code Current or Most Recent Employer - Telephone Number Current or Most Recent Employer - Supervisor Current or Most Recent Employer - Job Title Current or Most Recent Employer - Reason for leaving Current or Most Recent Employer - Start Date and End Date Current or Most Recent Employer - Final Salary or Hourly Rate Current or Most Recent Employer - Briefly list your duties Current or Most Recent Employer - May we contact? Yes No 2nd Most Recent Employer - Company Name 2nd Most Recent Employer - Address, City, Zip Code 2nd Most Recent Employer - Telephone Number 2nd Most Recent Employer - Supervisor 2nd Most Recent Employer - Job Title 2nd Most Recent Employer - Reason for leaving 2nd Most Recent Employer - Start Date and End Date 2nd Most Recent Employer - Final Salary or Hourly Rate 2nd Most Recent Employer - Briefly list your duties 2nd Most Recent Employer - May we contact? Yes No U.S. MILITARY SERVICE Branch of service: From: To: Rank and Type of service: Training/Experience received: EMPLOYMENT * Have you ever been fired or forced to resign? Yes No * Are you currently on layoff status with another employer and subject to recall? Yes No Additional skills which may be applicable to employement at Skaterz. Include computer skills * Type of work desired: * Salary desired: * Date available to work: * Full Time/Part Time: * Preferred work hours: How were you referred to our Organization? * Do you have any relatives who are employed by Skaterz? Yes No Please Specify: * Is there any information we would need about your name, or use of another name, for us to be able to check your work record? Yes No Please Specify: Please list any additional information that relates to your ability to perform the job for which you have applied such as licenses, professional memberships, hobbies, etc. * Are you able to perform the essential functions of the position with, or without, reasonable accommodation? Yes No * Have you ever been convicted of a crime? Yes No If yes, please explain - include the charge and the date ( Note: An Affirmative response to this question will not result in your automatic disqualification for employment.) APPLICANT STATEMENT AND RELEASE I understand that Skaterz follows an “employment at will” policy, in that I or Skaterz may terminate my employment at any time, or for any reason consistent with applicable state or federal law; this “employment at will” policy cannot be changed verbally or in writing, unless the change is specifically authorized in writing by the chief operating officer of this organization. I understand that this application is not a contract of employment. I understand that federal law prohibits the employment of unauthorized aliens; all persons hired must submit satisfactory proof of employment authorization and identity; failure to submit such proof will result in denial of employment. I understand this application will be active for a period of one year; after that time, if I wish to be considered for employment, I must submit a new application. I understand that Skaterz will thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorize all individuals, schools, and firms named therein, except my current employer if so noted, to provide any information requested about me, and I release them from all liability for damage in providing this information. I also understand that Skaterz will perform a criminal background check and a sexual predator check regarding me and I hereby expressly authorize such background checks to be performed by Skaterz. I certify that all the statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment. I certify that my application is correct and I agree with the Applicant Statement & Release above. I would like to exit from this process with the understanding that my changes will be lost.