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APPLICATION FOR EMPLOYMENT

1.  Name: __________________________________________________________________________________________________

2.  Address: _______________________________________________________________________________________________

3.  Telephone Number:  (Home) __________________________________     (Work) ________________________________

4.  Social Security Number:  ___________________________     5. Driver's License Number: ___________________

6.  How did you learn about our organization? ______________________________________________________________

7.  Are you eligible to work in the United States?  _____ Yes     _____ No

8.  Work Desired.

   a. Position(s) for which you are applying: ______________________________________________________________

   b. Salary Requirements: _________________________________________________________________________________

   c. Shift ________________________________________________________________________________________________

   d. Date available for work: _____________________________________________________________________________

9.  Qualifications.  Describe your skills and qualifications: ______________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

10.  Education.  List any schools, colleges or universities you have attended below:
				
     No. of Years____________	Did You Graduate?__________	Certificate, Degree or _____________________

Name of School		  Attended  	       Yes/No        		Course		    Diploma Earned  

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

11.  Have you ever been convicted of a crime (such conviction may be relevant if job related, but may not 

     necessarily bar you from employment.)  _____ Yes    _____ No   If yes, please explain: ________________

____________________________________________________________________________________________________________

12.  Are there any reasons why you would not be able to perform the duties of any position for which you 
     
     are applying?   _____ Yes     _____ No   If yes, please describe: _____________________________________

____________________________________________________________________________________________________________



13.  Employment History.  List your last three employers below, starting with your current employer.

=============================================================================================================

Employer name, address and telephone number		Employed From/To		Salary Start/End

_____________________________________________________________________________________________________________

Supervisor's Name: _______________________________________  Job Title: ______________________________________

Describe your duties: _______________________________________________________________________________________

Reason for leaving: _________________________________________________________________________________________

=============================================================================================================

Employer name, address and telephone number		Employed From/To		Salary Start/End

_____________________________________________________________________________________________________________

Supervisor's Name: _______________________________________  Job Title: ______________________________________

Describe your duties: _______________________________________________________________________________________

Reason for leaving: _________________________________________________________________________________________

=============================================================================================================

Employer name, address and telephone number		Employed From/To		Salary Start/End

_____________________________________________________________________________________________________________

Supervisor's Name: _______________________________________  Job Title: ______________________________________

Describe your duties: _______________________________________________________________________________________

Reason for leaving: _________________________________________________________________________________________

=============================================================================================================

14.  Set forth any additional information in support of your application you wish to bring to our attention:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

I verify that the information contained in this Application for Employment is true, and I authorize 
the Company to seek references from my current and former employers, as indicated by my signature on 
the attached authorization.  I agree to submit to a physical examination and drug screening as 
required by the Company.  I further agree that, if hired, either the Company or I may terminate our 
relationship at will, with or without notice, and for any reason.  Moreover, I understand that only 
the President of the Company may enter into any agreement concerning the length of my employment.

The Company is an equal opportunity employer.  This application for employment will be current for 
only sixty days.  A new application must be completed if the applicant wishes to be considered for 
employment after that time.

__________________________________________________	_____________________________________________________	
Signature						Date

UNDER MARYLAND LAW AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY APPLICANT FOR EMPLOYMENT OR PROSPECTIVE 
EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION 
AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT.  ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY 
OF A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $100.

							_____________________________________________________
							Signature