Have you ever been convicted of a crime, other than a minor traffic violation, had adjudication withheld, or pled no contest to a crime? Yes No
If YES, please state the type of crime and the circumstances with regard to each, including date of the conviction or pleas and the penalty, if any, imposed by the court.
NOTE: Answering YES to any of these questions may not necessarily disqualify you from the position you desire. Each action and explanation will be weighted/considered in relationship to the position for which you are applying.
AFFIRMATIVE ACTION FORM Government Agencies require reports on status of applicants. This data is for analysis and affirmative action only. Submission is voluntary. Failure to supply this information will not jeopardize or adversely affect any consideration you may receive for employment, or later advancement in employment.
Race/Ethnicity:
I attest to the truthfulness of any and all information and answers provided above. Any false or misleading statements will be grounds for denial of employment or discharge. I understand the company will be checking into my references and employment background. I authorize the Company to do so and release from liability anyone giving or obtaining such background information. This application does not constitute a contract of employment or an indication that any jobs are available. Any employment with the Company is atwill, meaning the employer or employee can end the employment relationship at any time for any or no reason and with or without notice. My signature below verifies that I have read and understand the foregoing statements.
I Agree to the Terms and Conditions Above.
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