Your name

Address

City
State
Zip

Phone Number

Your email

Work Availability
WeekdaysWeekendsBoth

Select Days you are unavailable to work
MTWThFSSn

Have you been you ever been convicted of a crime, excluding misdemeanors and summary offense, which has not been annulled, expunged, or sealed by court? YesNo

If yes, explain:

EDUCATION

High School
From To
Did you Graduate? YesNo

College
From To
Did you Graduate? YesNo

PREVIOUS EMPLOYMENT

Company Name
Address
Phone
Job Title
Responsibilities
From To
Reason for Leaving

Company Name
Address
Phone
Job Title
Responsibilities
From To
Reason for Leaving

DRIVING HISTORY
Do you have valid Driver's License or Photo Id? YesNo
DL/ID #
State
Exp. Date
Are you able to Drive Box Trucks? YesNo
If yes, how many years experience?
Have you ever been in any accidents while driving a motor vehicle? YesNo
If yes, briefly explain?

MEDICAL HISTORY

Are you able to work outdoors/stand for an extended period of time? YesNo
Have you had COVID-19? YesNo
If yes, provide date:
Have you been vaccinated? YesNo
If yes, provide date of final shot?
if you have you not been vaccinated, do you plan on being vaccinated? YesNo
If No, briefly explain why?

Do you have any medical conditions that may affect your ability to work? yesno
If yes, briefly explain?

This job requires heavy lifting, a minimum of 50lbs Are you physically capable of working for this company with no complications? YesNo
If no, briefly explain?

If selected for employment, are you will to submit a pre-employment drug screening test? YesNo

DISCLAIMER AND SIGNATURE
I certify that my answers 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.

Signature
Date

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