Personal Information
Last Name:
How long at current address?
First Name:
Home Phone:
 ()-
Middle Name:
Business Phone:
 ()-
Street Address:
Pager/Cell:
 ()-
City:
E-mail:
State:
Social Security Number:
Zip Code:

Were you ever employed by this Company? Yes    No
If Yes: Month and Year:
Location:
Position Desired:
Pay Expected:

Are you available for full-time work? Yes    No
If not, what days and hours can you work?
Are you willing to work overtime if asked? Yes    No
When will you be available to begin work?
Are you legally authorized to work in the United States? Yes    No
Special job related training or skills:
(machine operation, etc.)

Education Information
School
Name and Location of School
Course of Study
# of Years Completed
Did You Graduate?
Degree or Diploma
College
Yes No
High
Yes No
Elementary
Yes No
Other
Yes No

Employment History
Please provide accurate, complete information about full-time and part-time employment. Begin with present or most recent employment.
1.
 Company Name:
Address:
Name of Supervisor:
Your Job Title:
Can we contact this employer?
Yes No
Telephone:
Employed:
From (mm/yy):		    To:
Weekly Pay:
Start:		    Last:
Reason for Leaving:
2.
 Company Name:
Address:
Name of Supervisor:
Your Job Title:
Can we contact this employer?
Yes No
Telephone:
Employed:
From (mm/yy):		    To:
Weekly Pay:
Start:		    Last:
Reason for Leaving:
3.

Company Name:
Address:
Name of Supervisor:
Your Job Title:
Can we contact this employer?
Yes No
Telephone:
Employed:
From (mm/yy):		    To:
Weekly Pay:
Start:		    Last:
Reason for Leaving:

Miscellanious Information:
Membership in any Job-Related Organizations?
(Exclude those which may disclose your age, race, color, religion, sex, national origin or disability.)
Have you ever been refused bonding?
 Yes    No
If Yes, please explain:
Have you ever been convicted of a felony or felonies?
 Yes    No
If Yes, please explain:
(Answering yes to prior convictions will not prohibit employment, but will only be considered in relation to specific job requirements.)
Are you currently using illegal drugs?
 Yes    No
Are you willing to undergo a drug screen?
 Yes    No
Do you have a vaild driver's license?
 Yes    No
License #
Issuing State:
Expiration Date (mm/dd/yy):
How many moving violations have you been convicted of in the last 3 years?

Military Experience -

Describe the duties, special training or education you received:
If hired, can you furnish proof that you are at least 18 years of age?
 Yes    No

Signature
If I am employed by the company, I understand my employment can be terminated, with or without cause and with or without notice, at any time at the option of the Company or myself. I understand that, other than the President of the Company no manager, supervisor or representative of the Company has authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. Only the President of the Company has the authority to make any agreement contrary to the foregoing and then only in writing. I further expressly agree that, with respect to the at-will employment relationship, this constitutes the full, complete and final expression of the parties' intent concerning the nature of any employment relationship between myself and the Company.
I understand and agree with the statement above:
Effective July 1, 2001, you will be required to sign for authorization of our insurance agent to run an MVR Report on your driving record and send the results to Valley Muffler Shop, Inc. (d/b/a Midas) for review.
I understand and agree to the MVR: