Proud to be a Tobacco Free Workplace

APPLICATION FOR EMPLOYMENT You will only be contacted by an HR representative if you are selected for an interview

Application Date:

PERSONAL DATA

Last Name

First Name M.I. Other Names Previously Used

Street Address City

State

Zip

Home Phone

Alternate Phone

Email

Do you have steady transportation to work? Yes No Do you have a valid driver’s license? Yes No

Have you ever been convicted of or are you the subject of pending charges for any offense including traffic violations, but excluding offenses committed prior to your eighteenth birthday? Yes No If so, state details: (A conviction will not necessarily disqualify an applicant from consideration of employment)

Have you ever had a founded case of child abuse against you, or are you currently the subject of a charge or investigation regarding child abuse in this state or anywhere else? Yes No If so, state details:

JOB INTERESTS

Position Applied For: Desired Salary: $ Per How did you learn of this opening?

Walk-in Grafton IHN Website Friend/Relative Employment Agency School Print Advertisement

Job Board, please identify: Other, please identify source: For which location are you interested in applying?

Berryville Winchester Richmond Corporate Office Front Royal (I&T) Leesburg Sterling

Employment Desired: Full time Part time Either Full time or Part time

If part time, what days and hours? Date available for work:

Have you worked for Grafton before? Yes No If yes, when?

EDUCATION

Name and Address Did You Graduate? Degree & Major High School Yes No Diploma GED

College Yes No Graduate Yes No

For HR Use Only

VAI ___________

PROFESSIONAL CREDENTIALS

Type of License/Certification Issuing Authority Number Expiration Date

Please provide any additional education, knowledge, skills, or qualifications below.

EMPLOYMENT HISTORY

Are you currently employed? Yes No If yes, may we contact your current employer? Yes No Please complete all fields below, even if attaching a resume’

1) Current or Most Recent Employer

Dates Employed Description of Responsibilities From To

Address Telephone Number Hourly Rate/Salary

Starting Final Job Title

Supervisor (Name and Title) Reason for Leaving

2) Employer Dates Employed Description of Responsibilities From To Address

Telephone Number Hourly Rate/Salary Starting Final

Job Title

Supervisor (Name and Title) Reason for Leaving

3) Employer Dates Employed Description of Responsibilities From To Address

Telephone Number Hourly Rate/Salary Starting Final

Job Title

Supervisor (Name and Title) Reason for Leaving

4) Employer Dates Employed Description of Responsibilities From To

Address Telephone Number Hourly Rate/Salary

Starting Final Job Title

Supervisor (Name and Title) Reason for Leaving

JOB APPLICANT’S AGREEMENT, CERTIFICATION AND RELEASE PLEASE READ CAREFULLY

I certify that the information I have provided on this application and any accompanying resume and documents, if any, is true and complete to the best of my knowledge. I have not knowingly withheld any information that might, if disclosed, affect my application unfavorably. I understand that any false or misleading statements provided by me, either written or verbal, may be cause for denial or termination of employment. As part of my application for employment at Grafton, I authorize and consent to the release of any information of any nature concerning me including, but not limited to, my present or previous employment, educational records, educational credit verification, personal and professional reference data, credential verification, information concerning my driver’s license and driving record, any criminal record checks, any Child Protective Services registry checks, drug screening information, and any other similar data. I authorize the giving of any such information to the employees and agents of Grafton, and I authorize all of my employers, my reference individuals and any other entities which have information about me to respond to any question and to provide all oral or written information concerning me. Grafton may use a copy of this authorization as deemed necessary, which copy shall operate as if it were an original. I understand that only a member of the Human Resources department of Grafton has authority to make an offer of employment to me. I further understand that any offer of employment is conditional upon results satisfactory to Grafton of the screening, record checks and investigations listed above in the second paragraph. I understand that Grafton has broad discretion whether or not to hire me. I agree that, if hired, my employment will be “at will” for no definite period, and may be terminated at any time by either me or Grafton. In addition, I understand that Grafton has the right to change, modify or terminate its personnel policies, practices, benefits and other terms of employment, at any time. I release Grafton, its agents, and all entities who provide information as a result of this agreement, from all liability of any nature arising out of the disclosure, use, or review of any information given as a result of this agreement. By typing my name below I acknowledge and agree to the above statements.

Signature of Applicant όtƭŜŀǎŜ ¢ȅLJŜύ Date

AN EQUAL OPPORTUNITY EMPLOYER

Grafton IHN does not discriminate on the basis of race, religion, color, sex, age, national origin, disability, military status, or any other characteristic protected by applicable federal or state law.