PERSONAL INFORMATION NAME * PRESENT ADDRESS * PERMANENT ADDRESS * PHONE NO. * ARE YOU 18 YEARS OR OLDER? * Yes No ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS? * Yes No EMPLOYMENT DESIRED POSITION * POSITION ARE YOU EMPLOYED NOW? * IF SO MAY WE INQUIRE OF YOUR PRESENT EMPLOYER? * EVER APPLIED TO THIS COMPANY BEFORE? * EDUCATION GRAMMAR SCHOOL * HIGH SCHOOL * COLLEGE * TRADE, BUSINESS OR CORRESPONDENCE SCHOOL * GENERAL SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK ACTlVITIES: (CIVIC ATHLETIC ETC.) U. S MILITARY OR NAVAL SERVICE RANK PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES *This form has been revised to comply with the provisions of the Americans with Disabilities Act and the final regulations and interpretive guidance promulgated by the EEOC on July 26. 1991. EMPLOYMENT HISTORY DATE MONTH AND YEAR DATE MONTH AND YEAR DATE MONTH AND YEAR DATE MONTH AND YEAR WHICH OF THESE JOBS DlD YOU LIKE BEST? WHAT DlD YOU LIKE MOST ABOUT THIS JOB? REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR. THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTS. [Fill in name of state.) IT IS UNLAWFUL IN THE STATE OF TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY. Signature of Applicant * IN CASE OF EMERGENCY NOTIFY "I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED. MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE. AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY'S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. I UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT'S PRESIDENT, AND THEN ONLY WHEN IN WRONG AND SIGNED BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING. DATE SIGNATURE DO NOT WRITE BELOW THIS LINE INTERVIEWED BY: DATE: REMARKS: NEATNESS: ABILITY: HIRED:: Yes No POSITION: DEPT.: SALARY/WAGE: DATE REPORTING TO WORK: APPROVED:: This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination. This Application for Employment Form is sold for general use throughout the United States. TOPS assumes no responsibility for the inclusion in said form of any questions which, when asked by the Employer of the Job Applicant, may violate State and/or Federal Law.