Today's Date:

Position Applied for:

Alternate Choice:

Personal Information
First Name: Middle Name: Last Name:
Address 1: Address 2: City: State: Zip Code:
Email Address: Phone: In case of emergency contact:

More Information
Are you authorized to work in the United States? yes no	Do you have a reliable means of transportation? yes no
Are you age 18 or older? Note: If under 18, proof of age and work papers must be provided. yes no
Do you have any relatives currently employed by Hiller's? yes no
Have you ever been convicted of a felony? yes no	If yes, give specifics:
Hours Available: From: Until:	Available: Full Time Part Time
Days Available: Sun Mon Tue Wed Thu Fri Sat

I understand that the Company may require that I submit to a drug screening test prior to being hired. I consent to any drug screening test required by the Company. I also understand that if I am hired, the Company may require me to undergo a drug test at any time during my employment and an alcohol test as permitted by law. I agree to take such a test.

I certify that all of the answers and information given by me in this application are true, accurate and complete without qualification. If I am hired, I understand that if the Company, at any time determines that any of the requested information as withheld by me, or any of the statements furnished above were false, inaccurate or misleading, I will be subject to immediate dismissal once the facts become known.

I authorize investigation of all information contained in this application and also authorize full disclosure of my present and prior work records by any employer. I understand that employment arising out of this application is contingent upon the results of this investigation. I release any employer from any obligation to provide me with written notification of any information disclosed. I understand that this may include a record of disciplinary action assessed by the employer.

I recognize that this application is not an offer for a contract of employment. I further recognize and agree that if I am employed by the company such employment will not result in a contract for employment and that the Company may terminate my services at will, at any time, for any reason or no reason at all until such time as I complete my probationary period and am covered under the Collective Bargaining Agreement negotiated between the Company and the Union.