Job Applying For
    Social Security #


    apt #



    Telephone Number where you can be contacted
    Email Address
    Are you at least 18 years of age?
    Are you a U.S. citizen?
    Will you be able to perform the essential functions of the position for which you have applied?
    If NO, what accommodation to this condition would make it possible for you to do this job?
    Do you speak, read or write fluently a language other than English?
    On what date would you be available to work?
    Are you available to work:
    Are you on a lay-off and subject to recall?
    Will you work out of town?
    If the position you are applying for involves the driving of a vehicle or equipment which requires a license, do you have a valid license?
    If YES, please specify the type of license:
    List the following:
    License Number
    Expiration Date
    Have you had a motor vehicle accident or a moving violation in the past 3 years?
    If YES, please explain

    Previous employment (list present or last job first)

    Name of Employer
    Title or Duties of Position
    Rate of Pay
    Reason for Leaving

    "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal, and I agree to hold my employer harmless in the event of my dismissal based thereon.

    I authorize investigation of all statements contained herein and to do background checks to give you and all information concerning my previous employment and any pertinent information they may have, confidential or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

    I realize that under certain provisions of Iowa law, pre-employment drug testing could be a condition of my employment. I also acknowledge that the employer may require drug testing at a subsequent time providing that proper advance notice of testing is provided.

    I also recognize that I could be offered employment subject to appropriate medical examination and that such a report could nullify my ultimate employment by this employer. I agree to submit to physical examination if needed.

    I understand and agree that, if hired, my employment is for no definite period and may, regardless of the method of payment of my wages and salary, be terminated at any time without prior notice. If employment is obtained under this application, I will comply with all the rules and policies of my employer."