Last Name:  ________________________  First: __________________   Phone #: ______________

 Local Address: ____________________________   City: ______________________   Zip: ________

 Email Address: _________________________________

 Please list any pertinent experience you have gained:

In High School: __________________________________________________________
________________________________________________________________________

In College: ______________________________________________________________
________________________________________________________________________

Job: ____________________________________________________________________
________________________________________________________________________

 Comments: ____________________________________________________________________
 ______________________________________________________________________________

 Have you ever been convicted of felony?  ___Yes   ___No
 If yes, please describe:

 I understand that misrepresenting my background on this application is grounds for dismissal.

 Complete your schedule of work availability on the following page.

 Applicant Signature: _____________________________________________  Date: _____________