Name:

First

Last

Date:

Address:

City:

State:

ZIP Code:

Contact Phone Number

Position applied For:

Valid and current driver's license?

Yes
No

Date Available to Start:

Days And Hours Available:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Are you a citizen of the United States?

Yes
No

If no, are you authorized to work in the U.S?

Yes
No

Have you ever worked for this company?

Yes
No

If yes, when?

Have you ever been convicted of a felony?

Yes
No

If yes, explain:

Education – High School:

Address:

Number of years completed:

Did you graduate:

Yes
No

Education – College:

Address:

Number of years completed:

Did you graduate:

Yes
No

Education – Other:

Address:

Number of years completed:

Did you graduate:

Yes
No

Military Service – Branch:

From:

To:

Rank at Discharge:

Type of Discharge

Previous Employment – Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary: $

Ending Salary: $

From:

To

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes
No

Previous Employment – Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary: $

Ending Salary: $

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes
No

Previous Employment – Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary: $

Ending Salary: $

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes
No

Reference – Full Name:

Relationship:

Company:

Phone:

Reference – Full Name:

Relationship:

Company:

Phone:

Reference – Full Name:

Relationship:

Company:

Phone:

Disclaimer and Signature

Please Read Carefully Before Signing

Drug Testing Consent:

I understand that if I receive and accept a job offer from Lindyspring, my employment will not become effective until I have passed a medical examination that consists of/includes tests for the detection of drugs. I agree to submit to this examination within twenty-four hours of receiving a job offer and authorize the examining physician or medical services provider to inform Lindyspring of the results of my medical condition. I understand that Lindyspring reserves the right to withdraw its job offer to me if I adulterate my specimen, fail to submit to this examination or fail to pass the medical examination and will not consider me for re-employment for twelve months following my failure to pass a medical examination. I also understand that my passing this examination will be valid for thirty days from the date my results are reported. I hereby certify that the information given by me is true in all respects. I authorize Lindyspring and their representative to contact my prior employers and all others for the purpose of verification of the information I have supplied and release same from any liability resulting from the information released. I authorize employers, schools and other persons named on this application to provide any information or transcripts requested. If Lindyspring decides to engage an investigative consumer reporting agency to report on my credit and personal history I authorize you to do so. If a report is obtained you must provide, at my request, the name of the agency so I may obtain from them the nature and substance of the information contained in the report. I understand that misrepresentation or omission of facts may result in refusal to hire or in termination of employment. Employment with Lindyspring is also contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States. In the event that I am employed, I understand that I must comply with all company policies and rules. I further understand that employment and compensation can be terminated with or without cause or notice, at any time at the option of Lindyspring or the employee. This application is not a contract of employment between the applicant and Lindyspring. No words or actions of the Company, including employment offers or terms and conditions of employment are intended to establish and implied or expressed employment contract. AN EQUAL OPPORTUNITY/DRUG-FREE EMPLOYER This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Applicant's Signature:

Date: