PERSONAL INFORMATION

Last Name:	First Name:	Middle Name:	Maiden Name:
Street Address:	City:	State:	Zip:
Social Security Number:	Home Phone:	Cell Phone:	Email Address: An email address is required.Invalid format.
Date of Birth:
Are you a United States citizen?	Yes No	If no, do you have a valid work permit?	Yes No
Are you 18 years of age or older?	Yes No	If NO, what is your current age?
Have you ever been employed by Maidorganic?	Yes No	If YES, dates of employment & reason for leaving:
Do you have a valid driver’s license?	Yes No	If YES, State of issuance, license #, and expiration date:
How did you learn about this employment opportunity at Maidorganic? Check all that apply: Ad in newspaper Job Bulletin (Posting) Ad in Magazine Referral by employee If other, please specify:

EDUCATION

Name of School	City/State	Did you graduate?	If No, # of years left to graduate	If Yes, date of Graduation	Degree received	Major
High School:		Yes No
GED:		Yes No
Other School:		Yes No
College:		Yes No
HAVE YOU EVER BEEN CONVICTED OF A CRIME? No Yes If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offence(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

WORK AVAILABILITY

Days/hours available to work:

No Pref

Mon

Tues

Wed

Thurs

Fri

Employment desired FULL-TIME ONLY PART-TIME ONLY FULL-OR PART-TIME

How many hours can you work weekly?

Can you work evenings?

When can you start?

WORK EXPERINECE

Please detail your entire work history. Begin with your current or most recent employer. If you held multiple positions with the same organization, detail each position separately. Attach additional sheets if necessary. Omission of prior employment may be considered falsification of information. Please explain any gaps in employment. Include full-time military or volunteer commitments. PLEASE DO NOT complete this information with the notation “See Resume.”
PLEASE NOTE: Maidorganic LLC reserves the right to contact all current and former employers for reference information.

Dates Employed (most recent position) From: To:	Full time Part-time	Title
Starting Salary:	Organization Name and Address:
Final Salary:	Organization Name and Address:
Supervisor’s Name, Title and Phone #:	Other Reference Name, Title and Phone #:	Contact my current references: At any time At this time:
Primary duties:	Reason for Leaving:

Dates Employed (most recent position) From: To:	Full time Part-time	Title
Starting Salary:	Organization Name and Address:
Final Salary:	Organization Name and Address:
Supervisor’s Name, Title and Phone #:	Other Reference Name, Title and Phone #:	Contact my current references: At any time At this time:
Primary duties:	Reason for Leaving:

REFERENCES

Give the names of three persons NOT related to you

Name	Address	Telephone




PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION. I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize MAIDORGANIC LLC to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. I agree to a criminal background check, work history check, as well as a pre-employment drug screening. I also understand that this company does conduct random drug screenings as well. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of MAIDORGANIC LLC serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States, to file a State security questionnaire and State loyalty oath, and to comply with company and departmental regulations. I understand that if employed on a temporary basis, I would be paid for hours worked only, and would be ineligible for benefits including paid time off. If employed on a regular, benefits-eligible basis, I understand that I would be required to make mandatory contributions to the MAIDORGANIC LLC Retirement System or to an optional retirement program, if applicable. I understand that any benefits I receive may be subject to change or discontinuation at any time without prior notice. I understand that the first SIX MONTHS of regular employment represent a provisional period, during which I would not be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal.		I have read the statement on the left and agree to the terms .
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