Full Name (required): Social Security Number:    Email Address (required):    Present Address (required): City:   State/Province:   Zip Code:    State    AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY AB BC MB NL NT NS ON PE QC SK YT        Permanent Address (required): City:   State/Province:   Zip Code:    State    AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY        Referred By (required): Phone Number:    Are You Applying for a Full-Time or Part-Time Position?Salary Desired: Full-Time     Part-Time     Either    Position (required): Date You Can Start (required):    Are You Currently Employed?    Yes     No     What is Your Availability? (required):      Do You Have Reliable Transportation?    Yes     No Do You Smoke?    Yes     No     Former Employers (Please provide Employer Name, Address, Salary, Position  and Reason for Leaving) (required):       References (Please provide Name, Address and Years Known) (required):      AUTHORIZATION "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws." I have read this agreement in its entirety and agree to its authorization.