Employment Application Employment Application Click here to download a copy of this employment application form. General Information State —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Are you willing to undergo a physical examination by your personal physician, or by a physician designated by Meth-Wick? YesNo Do you have any relatives employed by Meth-Wick? YesNo If yes, in which department? How were you referred to Meth-Wick? Position applying for â€“ please be specific: (Click here for a full list of positions we're currently hiring.) The following conditions may be required at some point in a job assignment. If required, would you be willing to work: 1) Shift work? YesNo Shift Preference: DayEveningNight 2) Rotational work schedule? YesNo 3) Work other than Monday through Friday? YesNo 4) Overtime? YesNo What date would you be available to begin work? Employment desired: Full-TimePart-TimeTemporarySummerOccasional Education and Training High School: Graduated High School: YesNo College/University: Graduated College: YesNo College Degree, Diploma or Certificate: College Major/Field of Study: Other Education: Graduated Other Education: YesNo Other Education Degree, Diploma or Certificate: Other Education Major/Field of Study: Security Information Do you have a record of founded child or dependent adult abuse, or have you ever been convicted of a crime in this state or any other state? YesNo If yes, please briefly describe the circumstances of your conviction, indicating the date, nature and place of the offense and the disposition of the case: Employment Experience Include your last five (5) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. (Incomplete information could disqualify you from further consideration.) Employer #1: State —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Position Title: Supervisor's Full Name: Reason For Leaving: Start Date: End Date: Base Rate Of Pay: Summarize duties and responsibilities: Employer #2: State —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Position Title: Supervisor's Full Name: Reason For Leaving: Start Date: End Date: Base Rate Of Pay: Summarize duties and responsibilities: Employer #3: State —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Position Title: Supervisor's Full Name: Reason For Leaving: Start Date: End Date: Base Rate Of Pay: Summarize duties and responsibilities: Do you have any objections to our contacting your present employer to verify the above information? No, you may contact at any time.Do not contact now, contact at a later date. References Please give the names of three persons not related to you, whom you have known at least three (3) years. Reference #1: Reference #2: Reference #3: Please Read the Following Statements Carefully: The information that I have provided is accurate to the best of my knowledge and subject to verification by Meth-Wick. A material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of employment or, if employed, termination by Meth-Wick. Although management makes every effort to accommodate individual preferences, business needs at times make the following conditions mandatory: overtime, shift work, a rotating work schedule or a work schedule other than Monday through Friday. I understand and accept these conditions of my continuing employment. I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Meth-Wick and myself for either employment or the providing of any benefit. No promises regarding continued employment have been made to me, and I understand that no such promise or guarantee is binding upon Meth-Wick unless made in writing. I understand and agree to the terms and conditions listed above. I hereby authorize the addressed individual, company or organization to furnish The Meth-Wick Community with any relevant information they may require to arrive at an employment decision, and do hereby release the addressed individual, company, or organization and all individuals connected therewith, including Meth-Wick, from all liability for any damage whatsoever incurred in furnishing such information. The Meth-Wick Community, Inc. does not discriminate in hiring or employment on the basis of race, color, religion, national origin, sex, age, sexual orientation, veteran status or disability unrelated to the ability to perform essential job requirements. No question on this application is intended to secure information to be used for such discrimination. This application will receive active consideration for thirty days.