Job Application

Applicant's Information

Birth Date if UNDER 18










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:

Employment 2:

Employment 3:

Employment 4:

Personal References

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.