First Name   

Middle Initial   

Last Name   

City   

State   

Zip   

Phone Number   

Referred By   

Are You 18 Years Of Age Or   Older?   

Yes

No

Position Desired   

Date You Can   
 Start   

Salary Desired   

Are You Employed Now?   

Yes

No

May We Enquire About   
Your Present Employer?   

Yes

No

Have You Applied Here   
Before?   

Yes

No

When?   

Grammar   
School   

Subjects Studied  
Degree(s)  
Received  

High School   

College   

Trade,   
Business, or   
Correspondence   
School   

Subjects of Special Study   
 or Research Work   

Job Related Skills   
 (typing, etc..)   

Activities Other Than   
Religious (Civic, Athletic)   

“UNDER MARYLAND LAW AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY APPLICANT FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOTMENT. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $100.” “It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.” If you are being hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements. AUTHORIZATION I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal of hire, or dismissal if I have been employed, no matter when discovered by the Company. I understand that any employment is conditioned on a background check. I authorize the Company to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to the Company, without giving me prior notice of such disclosure. In addition, I release the Company, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure. I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be “At Will” and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing. If I am offered employment I agree to submit to a medical examination and drug test before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by the Company and as permitted by law. I consent to such examinations and tests, and I request that the examining doctor disclose to the Company the results of the examination, which results shall remain confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, and if I am hired a condition of my employment will be that I abide by the Company’s Drug and Alcohol Policy. I understand that filling out this form does not indicate there is a position open and does not obligate the Company to hire. If hired, I agree to abide by all Company work rules, policies and procedures. The Company retains the right to revise its policies or procedures, in whole or in part, at any time.