Employment Application

PERSONAL INFORMATION

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone *

Email Address *

Preferred Contact Method *

Phone - Call

Phone - Text

EMPLOYMENT RELATED

List the positions for which you are applying: *

Are you legally authorized to work in the United States? *

Yes

Are you below the age of 18? *

Yes

Have you previously applied for employment here? *

Yes

When did you apply? * +

Have you previously been employed by this company or its subsidiaries? *

Yes

If you have you previously been employed by this company or its subsidiaries, when? *

Do you wish to work: *

Full Time

Part Time

Temporarily

If part time, specify hours or days *

What is your minimum compensation required? (select one)

Type *

Hourly

Annual

Amount *

Are you aware of any circumstances which would restrict or prevent your employment with Butech (such as a non-compete or confidentiality agreement)? *

Yes

If there are circumstances which would restrict or prevent your employment with Butech, please explain. *

0/8000 characters

Do you have any commitments that might otherwise affect your employment with us?

0/8000 characters

Where did you hear about position? *

Date available for work. * +

EDUCATIONAL DATA

High School

High School Name

Address

City

State

No. of years completed

Did you receive a diploma or GED? *

Yes

College

College Name

Address

City

State

No. of years completed

Course of Study / Major

Degree / Certification Earned

Graduate School

Graduate School Name

Address

City

State

No. of years completed

Course of Study / Major

Degree / Certification Earned

Trade, Business, or Night School

Trade, Business, or Night School Name

Address

City

State

No. of years completed

Course of Study / Major

Degree / Certification Earned

Other

Other School Name

Address

City

State

No. of years completed

Course of Study / Major

Degree / Certification Earned

EMPLOYMENT HISTORY

List present employer or most recent employer first. May we contact these employers?

Yes

Employer 1

Company Name

Address

City

State

Phone

Start Date +

End Date +

Job Title

Supervisor/Manager

Starting Wage

Ending Wage

Duties

0/8000 characters

Reason for Leaving

Employer 2

Company Name

Address

City

State

Phone

Start Date +

End Date +

Job Title

Supervisor/Manager

Starting Wage

Ending Wage

Duties

0/8000 characters

Reason for Leaving

Employer 3

Company Name

Address

City

State

Phone

Start Date +

End Date +

Job Title

Supervisor/Manager

Starting Wage

Ending Wage

Duties

0/8000 characters

Reason for Leaving

Employer 4

Company Name

Address

City

State

Phone

Start Date +

End Date +

Job Title

Supervisor/Manager

Starting Wage

Ending Wage

Duties

0/8000 characters

Reason for Leaving

GENERAL INFORMATION

Please include any other information you think would be helpful to us in considering you for employment, such as work experience, articles/books published, activities, accomplishment, etc. (You may exclude all information indicative of age, sex, race, religion, color, national origin, or disability.)

0/8000 characters

Do you know of any reason why you cannot perform the essential functions of the job for which you are applying with or without reasonable accommodation? *

Yes

If you know of any reason why you cannot perform the essential functions of the job for which you are applying with or without reasonable accommodation, please explain. *

Have you been convicted of a criminal offense?
(An affirmative answer will not automatically disqualify you from being considered for employment.) *

Yes

If you have been convicted of a criminal offense, please explain. (HR Dept. may discuss with you.) *

Date * +

Place *

Nature *

MILITARY EXPERIENCE

Were you in U.S. Armed Forces? *

Yes

If you were in the U.S. Armed Forces please provide the following information:

Branch *

From * +

To * +

Rank at Separation *

Describe your duties *

0/8000 characters

REFERENCES

(Not employers or relatives--------at least three)

Reference 1

Name *

Occupation

Address

City

State

Email Address

Phone *

Reference 2

Name *

Occupation

Address

City

State

Email Address

Phone *

Reference 3

Name *

Occupation

Address

City

State

Email Address

Phone *

Reference 4

Name

Occupation

Address

City

State

Email Address

Phone

IMPORTANT NOTICE

Any offer received as a result of your submission of an application to Butech Bliss is conditioned upon
satisfactory completion of any physical examination required by Butech Bliss. If you are a successful applicant,
you will be notified of any physical examination requirements after an offer of employment is made.

Butech Bliss has made a commitment to maintain a work environment free from alcohol and drug abuse. A
substance screening test may be required as a part of any post-offer physical examination requirement, or may be required by itself. Failure to pass the substance screen test, or refusal to submit to it, will result in automatic revocation of any offer of employment.

The following consent form must be signed for further processing of your application, and will remain a
part of your permanent materials.

APPLICANT CONSENT

I understand and agree that I may be required to take and pass a physical examination and/or substance
screen test as a condition of my employment with Butech Bliss.

I understand that if I decline to sign this consent and decline to take the test or tests, the examination will
not be completed. Butech Bliss will be notified and my application for employment will be rejected or my
employment will be terminated. I understand that the test results and other medical information will be released only to authorized company personnel or testing facility personnel for appropriate consideration.

I hereby voluntarily consent to allow Butech Bliss, or its agents, to collect urine specimens from me for
testing for alcohol, drugs, and controlled substances. Further, I give my consent for the release of the test results to the appropriate members of the company’s management, or their appropriate agents. I understand that any positive results will preclude my employment.

AGREEMENT

(Please read the following statement carefully)

By placing my initials here, I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I understand that my employment can be terminated, with or without cause, at any time at the discretion of either the company or myself. I understand that no management official other than the president of the company has any authority to enter into any agreement contrary to the foregoing or make any oral assurance or promise of continued employment.

I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and any accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision.

Initials *

Name *

Date * +