Employment Application First Name (required) Last Name (required) Middle Initial Street Address (required) Apartment/Unit# City (required) State (required) Zip (required) Phone (required) Your Email (required) Position applied for (required) Full TimePart Time Date Available (required) Desired Salary (required) Are you over 18 years old? yesno Are you legally eligible for employment in the United States? (If offered employment, you will be required to provide documentation to verify eligibility). yesno Have you ever been employed in any facility of SchagrinGAS?. yesno If so please state facility name and location and dates of employment EDUCATION High School (required) Address (required) From (required) To (required) Did you graduate? (required) yesno Degree College Address (required) From (required) To (required) Did you graduate? (required) yesno PROFESSIONAL LICENSE OR MEMBERSHIP Type of Licence(s) Held State License Number License Expiration Date Other Professional Memberships (You need not disclose membership in professional organizations that may reveal information regarding race, color, sex, religion, national origin, ancesctry, age, disability, marital status, veteran status or any other protected status.) SKILLS Data Entry/ExcelCRTTypewriterWPMWordPerfectLotus 1,2,3MSWORD Other Software Skills RECORD OF CONVICTION During the last ten years have you ever been convicted of a crime other than minor traffic offense? If yes, explain A conviction will not necessarily automatically disqualify you for employment. Rather, such factors such as the age and date of conviction, seriousness and nature of crime, and rehabilitation will be considered. PREVIOUS EMPLOYMENT Company Phone Address Supervisor Job Title Starting Salary Ending Salary Responsibilities part timefull time From You may contact my previous supervisor for a reference Explain any gaps in work history Have you ever been discharged or asked to resign from a job? yesno Disclaimer I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize SchagrinGAS Company to verfiy their accuracy and obtain information on my work performance. I hereby release SchagrinGAS Company from and/all liability of whatever kind and nature which, at any time, could result from obtaining and having employment decision based on such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Employer. However, I further understand that neither the policies, rules, regulations of my employment nor anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the employer may terminate my employment at any time with or without notice or cause.