Last Name*

First Name*

Middle Name

Other Surname?

Street Address*

City*

State*

Zip Code*

Preferred Phone #*

Second Phone #, if any

SSN (optional)

E-Mail Address*

Driver License #*

Class of License*

License State*

License Expiration Date*

Today's Date*

Position Applied For :*

Are you seeking *

Full-TimePart-TimeTemporary

When could you start? *

Have you read the Essential Job Functions of the job for which you’re applying? *

YesNo

Can you perform the Essential Job Functions of the job for which you’re applying (with or without
accommodation)? *

YesNo

Are you legally authorized to work in the United States? *

YesNo

Have you ever applied here before? *

YesNo

If yes, when?

Were you ever employed here before? *

YesNo

If yes, when?

Education

High SchoolCollegeTrade SchoolOther

List three references who are not relatives or former employers:

Name*

Address*

Phone Number*

Name*

Address*

Phone Number*

Name*

Address*

Phone Number*

List employers in chronological order with current or last employer listed first. Account for all periods of time including military service and periods of unemployment

Employer 1

Name of Employer*

Job Title and Duties*

Dates of Employment (MO / YY)*

Supervisor*

Telephone Number*

Address*

City, State, Zip*

Reason for Leaving*

Employer 2

Name of Employer

Job Title and Duties

Dates of Employment (MO / YY)

Supervisor

Telephone Number

Address

City, State, Zip

Reason for Leaving

Employer 3

Name of Employer

Job Title and Duties

Dates of Employment (MO / YY)

Supervisor

Telephone Number

Address

City, State, Zip

Reason for Leaving

I have read and fully understand the foregoing statements. I seek employment under these conditions.

Describe any training or skills you have, or equipment you can operate, related to the job for which you are applying*

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

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 consideration for employment and may result in my dismissal if discovered at a later day.
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 that I may be required to successfully pass a drug screening examination. If required, I hereby consent to a pre- and/or
post- employment drug screen as a condition of employment.
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.
IF I AM EMPLOYED AT PEERLESS, I ACKNOWLEDGE THAT THERE IS NO SPECIFIED LENGTH OF EMPLOYMENT AND THAT THIS APPLICATION DOES NOT CONSTITUTE A CONTRACT FOR EMPLOYMENT. ANY SUCH EMPLOYMENT AGREEMENT MUST BE IN WRITING AND SIGNED BY BOTH THE PRESIDENT OF PEERLESS AND THE EMPLOYEE. ACCORDINGLY, EITHER I OR PEERLESS CAN TERMINATE MY EMPLOYMENT AT WILL, AT ANY TIME, WITH OR WITHOUT CAUSE.

Application Signature*

Date*

An Equal Opportunity Employer

We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job related factors.

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Job Application

High School

College

Trade School

Other

List three references who are not relatives or former employers:

List employers in chronological order with current or last employer listed first. Account for all periods of time including military service and periods of unemployment

Employer 1

Employer 2

Employer 3

I have read and fully understand the foregoing statements. I seek employment under these conditions.

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

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