We are an equal opportunity employer. All applicants
will receive consideration based on their qualifications
and without regard to Race, Creed, Religion, Age Disability,
Sex, National Origin, or any other unlawful factor.

ALL QUESTIONS MUST BE ANSWERED.

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GENERAL INFORMATION
Name
Last: First: M.I.:
Street Address			Telephone No.
			( ) -
City	State	Zip	Email Address
Position(s) applying for	Are there any hours you cannot work?
	Yes No		If yes, explain:
Do you require working papers? (under 18 years of age)			Available to start on
Yes No If yes, give date of birth:			Date:
Any relatives or friends working for us?
Yes No If yes, give names and locations:
Can you perform essential job functions with or without reasonable accommodations? Describe:
Have you ever been convicted of a crime?
Yes No If yes, explain: Such conviction may be relevant if job related, but does not necessarily bar you from employment.
Will you be able to provide proof of U.S. citizenship or permanent residency upon employment?
Yes No

EDUCATION
	Name of School	Address	Highest Grade Completed	Type of Diploma Degree - Major
Grammer
High School
College
Other
Other

EMPLOYMENT HISTORY (starting with most recent)

Employed from Mo Yr to Mo Yr Company Name Name and Position of Supervisor Salary (Start/End) Address Your job Title and Duties Reason for leaving Telephone No. ( )

Employed from Mo Yr to Mo Yr Company Name Name and Position of Supervisor Salary (Start/End) Address Your job Title and Duties Reason for leaving Telephone No. ( )

Employed from Mo Yr to Mo Yr Company Name Name and Position of Supervisor Salary (Start/End) Address Your job Title and Duties Reason for leaving Telephone No. ( )

If currently employed, may we contact your employer for reference purposes?

Yes No

If yes, give name, position and telephone number of person to be contacted:

Name: Position: Telephone #:( ) -

INTERNAL HR USE ONLY: 1. I hereby declare that the information provided by me in this application is true, correct and complete to the best of my knowledge and that any misrepresentation or falsification of this information shall be considered cause for cancellation of this application and/or separation from LIA's service if I have been employed. 2. I authorize LIA to investigate and check any of the foregoing data and references. 3. I agree to conform to the policies and procedures of LIA and I understand that work schedules are subject to change and that overtime may be required. 4. I understand that just as I am free to resign at any time, LIA reserves the right to terminate my employment at any time, for any lawful reason, with or without cause and without prior notice. I understand that no representative of LIA has the authority to make any statement to the contrary.

Date: __________________	Signature: ________________________________________
SS#: _____ - _____ - _____

Interviewed by:

Date: