C.A.P.S Inc.

Our company is an equal opportunity employer and will consider all applicants for all positions equally without regard to race, sex, age, color, religion, national origin, veteran status, disability or any other legally protected characteristic.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered. This application will remain active for thirty days from the date it is filled out.

First Name

Middle Initial

Last Name

Phone

Address

City

State

Zip Code

Are you over 18 years old? YesNo

Are you a citizen of the U.S. or do you have the legal right to be employed in the United States? YesNo

Have you ever been found guilty of any crime (excluding minor traffic violations) including DWI?) YesNo

If Yes, please state the offense, date and disposition.

Note: A conviction will not necessarily disqualify you from employment.

Employment Desired:

Position Applied For

Salary Desired

Date Available to Start

Have you ever applied to our company before? YesNo

Have you ever worked for our company before? YesNo

If you answered yes to either question above, please state when and where you applied and/or worked.

How did you learn of our company and/or position?

Are you wanting to work First Shift (7 a.m. to 7 p.m.) / Second Shift (7 p.m. to 7 a.m.) / Either?

If there are any days or hours you would be unable or unwilling to work, please explain:

Education

High School

Name, Address & Location

Graduate? YesNo

Course Studied

College

Name, Address & Location

Graduate? YesNo

Course Studied

Trade School

Graduate? YesNo

Course Studied

List and describe any other school or specialized training:

Military

Have you ever served in the military? YesNo

Service Branch

Date Entered

Date Separated

Final Rank

Capability / Reliability

Is there any reason you would be unable or unwilling to perform any of the tasks required by the job you are applying for? YesNo

If yes, please explain:

Have you ever been disciplined for violating company safety rules and regulations? YesNo

If yes, please explain:

Is there any reason why you would be unable or unwilling to report to work on time every day on a regular and consistent basis? YesNo

If yes, please explain:

Work History

List names of employers in consecutive order with current or last employer listed first. Account for all periods of time including military service and any of unemployment. If self-employed, give firm name and supply business references.

PLEASE GIVE MONTH AND YEAR - DO NOT REFERENCE YOUR RESUME.

Employer Name

Phone Number

Address

Street Address, City, State, Zip Code

Name/Title of Supervisor

Your Title

Employment Start Date

Month / Year

Employment End Date

Month / Year

Starting Salary

Starting pay $

End Salary

Ending pay $

Duties

Reason for Leaving

Employer Name

Phone Number

Address

Street Address, City, State, Zip Code

Name/Title of Supervisor

Your Title

Employment Start Date

Month / Year

Employment End Date

Month / Year

Starting Salary

Starting pay $

End Salary

Ending pay $

Duties

Reason for Leaving

Employer Name

Phone Number

Address

Street Address, City, State, Zip Code

Name/Title of Supervisor

Your Title

Employment Start Date

Month / Year

Employment End Date

Month / Year

Starting Salary

Starting pay $

End Salary

Ending pay $

Duties

Reason for Leaving

Supplemental Employment Information

If you worked in any of your previous positions under another name, please give that name(s):

Are you currently employed? YesNo

If yes, may we contact your current employer? YesNo

Have you ever been fired, or asked to resign, from a job? YesNo

If yes, please explain:

Special Skills

Use the space below to describe why you are interested in working for our company and please list those skills and abilities which you feel will qualify you for a position with us.

References

Name

Address

Street Address, City, State, Zip Code

Phone Number

Occupation

Name

Address

Street Address, City, State, Zip Code

Phone Number

Occupation

Name

Address

Street Address, City, State, Zip Code

Phone Number

Occupation

I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application for or during any views may be grounds for my immediate discharge.

I hereby authorize the Company to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements.

I agree that, if I am employed, I will abide by all the rules and regulations of the Company. I understand that the taking of drug and alcohol tests when given pursuant to Company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for my immediate termination. I further understand that nobody in the company is authorized to enter into any written or verbal employment contract with me for any definite period of time without the express consent of the President of the Company. I also understand that my employment is “at-will” and may be terminated by myself or by the Company at any time for any reason or no reason at all, with or without prior notice.

Signature

Employment Application

Employment Desired:

Education

Military

Capability / Reliability

Work History

Supplemental Employment Information

Special Skills

References

Employment Application