First Name:
Middle Name:
Last Name:
Address (No. & Street):
Apt. #:
City:
State:
Zip:
Phone Number:
Alternate Phone Number:
Last 4 Digits of Social Security Number:
Type of work desired:
1st Choice:
1st Choice Shift:
1st Choice Salary:
Type of work desired:
2nd Choice:
2nd Choice Shift:
2nd Choice Salary:
Days and Hours Available Weekdays:
Days and Hours Available Weekends/Holidays:
Full Time/Part Time	Full Time Part Time On Call W/E Program
I can furnish the proper documents to prove my right to work in the U.S.(i.e. picture ID and Social Security Card, Birth Certificate, U.S. passport, Certificate of U.S. Citizenship or Naturalization; unexpired foreign passport or resident alien card, both with employment authorization, etc.):	Yes No
Are you at least 18 years of age?	Yes No
Are you at least 16 years of age?	Yes No
Have you ever been employed by Eastmont Towers?	Yes No
If yes, list dates and position:
Do you have any relatives working at Eastmont Towers?	Yes No
If yes, list them:
Have you had military service?	Yes No
If yes, branch:
If yes, date of service:	From: To:
If yes, rank at discharge:
Who referred you to us for employment?	Walk in Employee referral Newspaper (which one): Employment agency (which one): Internet site (which one): Other:
May we contact your present employer?	Yes No

If your former employment references, education or military service are under a name other than indicated, please list below.:
First Name:
Last Name:
From	To	Name of Employer, City, State, Phone No	Salary	Position	Supervisor's Name	Reason for Leaving

Name and Location of High School:
Graduate?:	Yes No
College, Trade, Business or Correspondence:
Graduate?:	Yes No
Title/Degree:
Major/Subject:

Extracurricular Activities, Member of Professional Org., Honors rec'd., volunteer or community service or other qualifications:

Professional Licenses and/or Certifications:
Type	Organization or State Issued	Date Issue	Number

References
Name	Address	Zip	Home Phone No.	Work Phone No.

Have you ever been convicted of any offense other than minor traffic violations?:	Yes No
If yes, list date, nature of offense and place:

PLEASE READ: By signing below or submitting this form online, I give Eastmont Towers the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I acknowledge that negative results could result in my not being hired, or if hired, in my employment being terminated. I consent to take the physical examination and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform. If hired, I realize that the relationship between me and Eastmont Towers would be one of employment at will, which means that any employee may leave at any time for any reason upon reasonable and appropriate notice and any employee may be terminated at any time for any reason. I hereby certify that all of the above answers and statements are true and correct and that there are no omissions of any kind whatsoever. I understand that I may be immediately discharged for any false statements or answers in this application or any omissions made by me.

Print Name	Date
Email address (only used for sending a copy of the filled in application):
On-line submission of this form has the same effect as a signature.