Job Application Applicant's Information Full Name* Email* Phone* Address Are you at least 18 years of age? YES NO Birth Date if UNDER 18Month/ Day/Year How did you find out about this job? Do you have any relatives working here? (list names & relationship) What job are you applying for? Have you worked for us before? YES NO If YES, where? Have you ever been convicted of a crime? YES NO If YES, please explain: Do you have any PENDING criminal charges? YES NO If YES, please explain: Do you have a valid New York State Driver's License? YES NO • Do you have ANY convictions related to moving violations within the last 3 years? (i.e. speeding, cell phone use, failing to yield, etc.) YES NO • Have you ever had your license suspended/revoked? YES NO • Have you ever been convicted of DWI or any incident involving harm to persons/property while driving? YES NO If YES to any of these driving questions, please explain: What hours of the day are you able to work? Number of hours per week you are able to work: Days of availability: M T W TH F S SU Education HIGH SCHOOL Name of school: City/State: Did you graduate? YES NO Degree/Diploma Rec'd COLLEGE Name of school: City/State: Did you graduate? YES NO Degree/Diploma Rec'd OTHER Name: City/State: Did you graduate? YES NO Degree/Diploma Rec'd CREDENTIALS LICENSE Profession/Skill Issuing Authority ID Number Expiration Date REGISTRATION Profession/Skill Issuing Authority ID Number Expiration Date CERTIFICATION Profession/Skill Issuing Authority ID Number Expiration Date OTHER Profession/Skill Issuing Authority ID Number Expiration Date employment History List your last 4 employers, list most recent first. **Do NOT leave any gaps of 2 months or more. Provide an explaination for any lapse in employment history.** Employment 1: Date From / To Company Name Position Supervisor Phone # Reason For Leaving Employment 2: Date From / To Company Name Position Supervisor Phone # Reason For Leaving Employment 3: Date From / To Company Name Position Supervisor Phone # Reason For Leaving Employment 4: Date From / To Company Name Position Supervisor Phone # Reason For Leaving Personal References Name Occupation Relationship Phone # Name Occupation Relationship Phone # Applicant's Agreement I hereby represent that each answer to a question herein and on any attachments to the application and all other information otherwise furnished is true and correct. I further represent that such answers and information constitute a full and complete disclosure of my knowledge with respect to the question or subject to which the answer or information relates. I understand that any incorrect, incomplete or false statements or information furnished by me during the selection process will subject me to disqualification from consideration or discharge at any time. I hereby authorize my former employers to give any information they may have concerning me. I understand that if hired, any offer of employment is subject to satisfactory criminal background & fingerprinting checks. I understand that Empower is a drug free workplace and I will be required to submit to and pass a drug test prior to beginning employment. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release Empower, and/or its representatives, from any and all liability which may be incurred as a result of collecting such information. I understand this Application for Employment does not constitute an expressed or implied contract of employment and, if hired, I have the right to terminate my employment for any reason at any time. I AGREE YES