<p>USTA NORTHERN Employment Application </p><p>We appreciate your interest in working at USTA Northern. As an equal opportunity employer, our employment practices are in accordance with the laws that prohibit discrimination against qualified individuals on the basis of race, religion, gender, age, disability, national origin, veteran’s status or any other protected status.</p><p>This application form was designed for use by people applying for various types of positions – professional, technical, clerical and administrative. Please answer only the questions that apply. All information will be treated confidentially. PLEASE TYPE or PRINT.</p><p>APPLICANT INFORMATION</p><p>Last Name First M.I. Date</p><p>Street Address Apartment/Unit #</p><p>City State ZIP</p><p>Phone E-mail Address</p><p>Date Available Social Security No.</p><p>Position Applied for Salary Desired</p><p>If hired, can you provide proof that you are at least 18 years of age or, if under, do you have a permit to work? YES NO </p><p>Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO </p><p>Have you ever worked for this company? YES NO If so, when?</p><p>EDUCATION</p><p>High School Address</p><p>From To Did you graduate? YES NO Degree</p><p>College Address</p><p>From To Did you graduate? YES NO Degree</p><p>Other Address</p><p>From To Did you graduate? YES NO Degree</p><p>REFERENCES Please list if available.</p><p>Full Name Relationship</p><p>Company Phone ( )</p><p>Address</p><p>Full Name Relationship</p><p>Company Phone ( )</p><p>Address</p><p>1 PREVIOUS EMPLOYMENT</p><p>Company Phone ( )</p><p>Address Supervisor</p><p>Job Title Starting Salary $ Ending Salary $</p><p>Responsibilities</p><p>From To Reason for Leaving</p><p>May we contact your previous supervisor for a reference? YES NO </p><p>Company Phone ( )</p><p>Address Supervisor</p><p>Job Title Starting Salary $ Ending Salary $</p><p>Responsibilities</p><p>From To Reason for Leaving</p><p>May we contact your previous supervisor for a reference? YES NO </p><p>Company Phone ( )</p><p>Address Supervisor</p><p>Job Title Starting Salary $ Ending Salary $</p><p>Responsibilities</p><p>From To Reason for Leaving</p><p>May we contact your previous supervisor for a reference? YES NO </p><p>TRAINING Check any of the following skills you possess, if you believe they are relevant to the position you are applying for:</p><p>Word Processing </p><p>Data Entry </p><p>Microsoft Word </p><p>Microsoft Excel </p><p>Microsoft PowerPoint </p><p>Other:</p><p>2 A conviction record will not necessarily be a bar to employment. The type and seriousness of the crime, the frequency of violations, your age at the time of conviction, the date of conviction or the time elapsed since such date as well as your work and educational history, employment references and recommendations will be part of the employment decision process.</p><p>I specifically authorize USTA Northern to investigate my background, including any and all references, available criminal and other judicial records, and my credit record, where applicable to the position for which I am applying and consistent with applicable law. I understand that USTA Northern will notify me if and when a credit record investigation is performed, and the sources investigated. I authorize USTA Northern to use all legal means at its disposal to assess my suitability for employment. I make this authorization in return for USTA Northern's consideration of me for employment, and I specifically release and hold USTA Northern harmless for any and all liabilities arising out of their investigation of my application for employment. ______(initial)</p><p>I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this information is grounds for dismissal. I hereby authorize every one of the former employers designated on this application to answer any questions about my employment, including assessments of my job performance and ability, which may be requested by USTA Northern in connection with my application for employment with USTA Northern. Furthermore, I hereby release each and every one of my former employers from any and all liability, of any type, for providing accurate information. ______(initial)</p><p>DISCLAIMER AND SIGNATURE</p><p>I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.</p><p>Signature Date</p><p>3</p>