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Employment Application

You must complete the entire application in order for it to be considered, so please take your time and fill in every field. When you are finished press the 'send' button at the bottom and your application will be sent to our Human Resources Department. A representative from Human Resources will contact you if your application is selected for further consideration. Thank you for applying with Priority One!

POSITION APPLYING FOR: SS#:

NAME: (last) (first) (middle)

STREET ADDRESS: PHONE:

CITY / STATE / ZIP: DESIRED SALARY: $

Are you able at the time of employment to submit verification of your legal right to work in the US?

(Verification and completion of Form I-9 must be submitted no later than three business days after date of

hire.)

YES NO

If under the age of 18, can you produce the necessary work certificate at the time of employment?

YES NO N/A

Type of Employment Desired? Full Time Part Time

Are you willing to work overtime? YES NO

Date you are available to start?

Have you ever applied with this company before? YES NO

If you have applied with this company before when did you apply?

Where?

Within the past ten (10) years, have you been convicted of a felony? (Do not include convictions that were

sealed, eradicated, erased, or expunged; convictions that resulted in a referral to a diversion program; or

marijuana-related convictions that are more than two (2) years old.) YES NO

If yes, please explain so that individual circumstances can be considered:

NOTE:

• Criminal convictions will not automatically disqualify an applicant from a particular job. The

company will consider the nature of the crime, its seriousness, whether the conviction(s) substantially

relates to the position’s functions and qualifications, the frequency of convictions, the applicant’s age

at the time of conviction, the time elapsed since the date of conviction or completion of jail sentence,

the applicant’s entire work and educational history, and employment references and recommendations.

• An ex-offender who is denied employment may, upon written request, receive a statement of the

reason(s) for denial within 30 days of the applicant’s request for such information.

This does not include convictions under California Health and Safety Code 11357(a) or (b), 11360 (c), 11364,

11365, or 11550 related to marijuana which occurred two or more years before the instant application

Have you ever initiated an act of violence in the workplace? YES NO

If yes, please explain so that individual circumstances can be considered.
(answering yes answer will not automatically disqualify you from employment.)

List special technical skills that you feel qualify you for the job for which you are applying
(e.g., computer programming / language, software, equipment operation, special tools or machines, etc.):

School Name/ Location	Course of Study	Graduate?	Degree / Major

HONORS RECEIVED:

WORK EXPERIENCE:

Start with your present or last place of employment. You may include any verifiable work performed on a

volunteer basis, internships, or military service. (Résumés Are Not A Substitute For A Completed Application.)

EMPLOYER INFORMATION:

NAME: TYPE OF BUSINESS:

PHONE: DATES EMPLOYED: from to

JOB TITLE: SUPERVISORS NAME/TITLE:

STARTING WAGES: $ per

FINAL WAGES: $ per

REASON FOR LEAVING: DUTIES:

MAY WE CONTACT THIS EMPLOYER? YES NO

EMPLOYER INFORMATION:

NAME: TYPE OF BUSINESS:

PHONE: DATES EMPLOYED: from to

JOB TITLE: SUPERVISORS NAME/TITLE:

STARTING WAGES: $ per

FINAL WAGES: $ per

REASON FOR LEAVING: DUTIES:

MAY WE CONTACT THIS EMPLOYER? YES NO

EMPLOYER INFORMATION:

NAME: TYPE OF BUSINESS:

PHONE: DATES EMPLOYED: from to

JOB TITLE: SUPERVISORS NAME/TITLE:

STARTING WAGES: $ per

FINAL WAGES: $ per

REASON FOR LEAVING: DUTIES:

MAY WE CONTACT THIS EMPLOYER? YES NO

APPLICANT CERTIFICATION

I understand and agree that if driving is a requirement of the job for which I am applying, my employment

and/or continued employment is contingent on possessing a valid driver’s license and automobile liability

insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or

alcohol testing program consistent with applicable federal, state, and local law. If the Company has such

a program and I am offered a conditional offer of employment, I understand that if a pre-employment

(post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work

under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local

law. I also understand that all employees of the location, pursuant to the Company’s federal, state, and

local law, may be subject to urinalysis and/or blood screening or other medically recognized tests

designed to detect the presence of alcohol or controlled drugs. If employed, I understand that the taking

of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and

drug testing consistent with the Company’s policies and applicable federal, state, and local law.

If employed by the Company, I understand and agree that the Company, to the extent permitted by

federal, state, and local law, may exercise its right, without prior warning or notice, to conduct

investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and,

in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to the extent permitted by federal, state,

and local law, I may be required to sign a confidentiality, non-compete, and/or conflict of interest

statement.

I certify that all of the information on this application, my résumé, or any supporting documents is

complete and accurate to the best of my knowledge. I understand that any falsification,

misrepresentation, or omission of any information may result in disqualification from consideration for

employment or, if employed, disciplinary action, up to and including immediate dismissal.

I UNDERSTAND THAT NEITHER THIS APPLICATION NOR ANY COMMUNICATION BY A MANAGEMENT

REPRESENTATIVE IS INTENDED TO CREATE OR DOES CREATE A CONTRACT OF EMPLOYMENT, OFFER, OR

PROMISE OF EMPLOMENT. I ACKNOWLEDGE THAT IF HIRED BY THE COMPANY, EMPLOYMENT IS ON AN

AT-WILL BASIS. THIS MEANS THE COMPANY IS FREE TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH

OR WITHOUT CAUSE OR ADVANCE NOTICE, IN ACCORDANCE WITH STATE LAW, AND ACCEPTANCE OF

EMPLOYMENT IS NOT A CONTRACT OF EMPLOYMENT FOR ANY SPECIFIED TIME. SIMILARLY, I AM FREE TO

TERMINATE MY EMPLOYMENT WITH THE COMPANY AT ANY TIME FOR ANY REASON. THIS AT-WILL PROVISION

MAY BE MODIFIED OR WAIVED ONLY IN A WRITTEN AGREEMENT SIGNED BY AN AUTHORIZED REPRESENTATIVE

OF THE COMPANY AND ME.

I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERTAND THAT THE

COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT

THAT IT WILL NOT MODIFY ITS AT-WILL EMPLOYMENT POLICY.

I authorize the Company or its agents to confirm all statements contained in this application and/or

résumé as it relates to the position I am seeking and to the extent permitted by federal, state, or local

law. I agree to complete any requisite authorization forms for the background investigation.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish

the above-mentioned information. I hereby release, discharge and hold harmless, to the extent permitted

by federal, state, and local law, any party delivering information to the Company or its duly authorized

representative pursuant to this authorization from any liability, claims, charges, or causes of action which

I may have as a result of the delivery or disclosure of the above requested information. I hereby release

from liability the Company and its representative for seeking such information and all other persons,

corporations, or organizations furnishing such information.

I understand this Company hires only individuals who are legally eligible to work in the United States.

Applicant Signature: Date:

If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or

legal guardian. Signature by the applicant’s parent or legal guardian constitutes acknowledgement by the

applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state,

and local law, can test the applicant for controlled substances, conduct inspections of property without

notice, and communicate screen results to Company personnel who need to know, the applicant, and the

applicant’s legal guardian.

Parent / Legal Guardian: Witness:

Date: Date:

FEDERAL AND / OR STATE LAW MAY PROHIBIT THE USE OF POLYGRAPH OR SIMILAR TESTS AS WELL.