EMPLOYMENT APPLICATION Personal InformationFirst Name* Last Name* Social Security No.* Home Address* City* State* Zip* Home Telephone Business Telephone May we contact you at work? Yes No Position Applying for: Date Available: MM slash DD slash YYYY How were you referred to La Boit, Inc.? If you are under 18 years of age, please state your date of birth: MM slash DD slash YYYY Education High School - Name and Address of SchoolHigh School Name High School Address High School City High School State High School Zip Degree/Area of Study Number of years attended Graduated (check one)* Yes No College - Name and Address of SchoolCollege Name College Address College City College State College Zip College - Degree/Area of Study College - Number of years attended Graduated (check one)* Yes No Graduate School - Name and Address of SchoolGraduate School Name Graduate School Address Graduate School City Graduate School State Graduate School Zip Graduate School - Degree/Area of Study Graduate School - Number of years attended Graduated (check one)* Yes No Other - Name and Address of SchoolOther - School Name Other - School Address Other - City Other - State Other - Zip Other - Degree/Area of Study Other - Number of years attended Graduated (check one)* Yes No U.S. Military ServiceBranch of Service Technical Specialization Rank Attained LegalAre you a U.S. citizen or do you have a legal right & necessary documents to work in the U.S.? Yes No (Identity and employment eligibility of all new hires will be verified as required by the Immigration Reform and Control Act of 1986).Were you ever discharged by any company? Yes No If so, give name of company(ies) Reason for discharge? Have you ever been convicted of a crime other than a minor traffic violation? Yes No If yes, please explain offense and final disposition:Employment History List employment starting with your most recent position. Account for any time during this period that you were unemployed by stating the nature of your activities.May we contact your present employer? Yes No May we contact your past employer? Yes No Please indicate if you were employed under a different name. EmployerFrom MM slash DD slash YYYY To MM slash DD slash YYYY Name and Address of Employer Name and Address of EmployerAddress of Employer City of Employer State of Employer Job title Supervisor Starting Salary or Wages Final Salary or Wages List Major Duties Reason for Leaving EmployerFrom MM slash DD slash YYYY To MM slash DD slash YYYY Name and Address of Employer Name and Address of EmployerAddress of Employer City of Employer State of Employer Job title Supervisor Starting Salary or Wages Final Salary or Wages List Major Duties Reason for Leaving EmployerFrom MM slash DD slash YYYY To MM slash DD slash YYYY Name and Address of Employer Name and Address of EmployerAddress of Employer City of Employer State of Employer Job title Supervisor Starting Salary or Wages Final Salary or Wages List Major Duties Reason for Leaving Have you ever worked at La Boit, Inc.? Yes No References Business references: (do not list relatives) (please indicate if you were employed under a different name)Reference Name Reference Address Work Phone # Title Years Known Reference Name Reference Address Work Phone # Title Years Known Reference Name Reference Address Work Phone # Title Years Known Please read carefully In submitting this application for employment, I understand that an investigation may be made whereby information is obtained regarding my character, previous employment, general reputation, educational background, credit record and/or criminal history. I authorize anyone possessing this information to furnish it to La Boit, Inc. and/or a 3rd party company upon request and I release anyone so authorized, La Boit, Inc. and any 3rd party company from all liability and damages whatsoever in furnishing, obtaining or using said information. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate dismissal. I understand also, that I am required to abide by all rules and regulations of La Boit, Inc. I understand and agree that if employed, the employment will be ‘at will’. That is, either I or La Boit, Inc. may end the employment relationships at any time, for any reason, or for no reason. I understand that receipt of this application by La Boit, Inc. does not imply employment and that this application and/or any other La Boit, Inc. documents are not contracts of employment.APPLICANT’S SIGNATURE* DATE SIGNED*