<p> BLACKBURN LAW FIRM, PLLC APPLICATION FOR EMPLOYMENT</p><p>BLACKBURN LAW FIRM, PLLC IS AN EQUAL OPPORTUNITY EMPLOYER AND DOES NOT DISCRIMINATE AGAINST ANY INDIVIDUAL IN ANY PHASE OF EMPLOYMENT IN ACCORDANCE WITH THE REQUIREMENTS OF VARIOUS FEDERAL, STATE, AND LOCAL LAWS WHICH PROHIBIT DISCRIMINATION BASED ON RACE, COLOR, SEX, RELIGION, SEXUAL ORIENTATION, NATIONAL ORIGIN, VETERAN STATUS, ANCESTRY, AGE (AS PRESCRIBED BY LAW), DISABILITY OR ANY OTHER CHARACTERISTIC PROTECTED BY LAW.</p><p>FOR PROPER CONSIDERATION, ANSWER COMPLETELY AND ACCURATELY. Please do not respond “reference resume”.</p><p>(PLEASE PRINT OR TYPE) PERSONAL INFORMATION NAME (LAST) (FIRST) (MIDDLE) EMAIL ADDRESS</p><p>HOME ADDRESS AREA CODE/TELEPHONE NUMBER</p><p>CITY STATE ZIP</p><p>DATE AVAILABLE POSITION DESIRED (1st CHOICE) 2ND CHOICE TO START WORK</p><p>EDUCATION DATES NAME OF SCHOOL DID YOU TYPE OF DEGREE/ ATTENDED GPA GRADUATE? MAJOR CITY AND STATE FROM TO</p><p>HIGH SCHOOL </p><p>COLLEGE OR UNIVERSITY</p><p>MILITARY OR SPECIAL SCHOOLS</p><p>OTHER SCHOOLS</p><p>IF ADDITIONAL INFORMATION, PLEASE ATTACH AND INITIAL. WORK EXPERIENCE LIST ALL FULL-TIME, COOPERATIVE, MILITARY, OR SUMMER WORK EXPERIENCE FOR TEN YEARS. START WITH YOUR MOST RECENT EMPLOYER AND CONTINUE WITH NEXT PREVIOUS EMPLOYER. INDICATE ALL PERIODS OF EMPLOYMENT. USE ADDITIONAL SHEET, IF NECESSARY. TITLE OF JOB HELD COMPANY NAME, ADDRESS, & PHONE MO/YR. RATE OF PAY REASON FOR LEAVING NAME OF SUPERVISOR FROM $ START</p><p>TO $ FINAL</p><p>FROM $ START</p><p>TO $ FINAL</p><p>FROM $ START</p><p>TO $ FINAL PROFESSIONAL REFERENCES YEARS NAME ADDRESS PHONE POSITION KNOWN</p><p>LIST ANY PROFESSIONAL LICENSES, CERTIFICATIONS, OR MEMBERSHIPS (INCLUDE DATES OBTAINED).</p><p>STARTING RATE EXPECTED: MAY WE CONTACT YOUR PRESENT EMPLOYER? $ YES NO</p><p>HOW WERE YOU REFERRED TO BLACKBURN LAW FIRM? Internet Job Fair Web Site Agency Other Please explain:</p><p>ARE YOU AT LEAST 18 YEARS OF AGE? (If not, you may be required to provide authorization to work.) YES NO IF YES, INDICATE AGE ______. ARE YOU LEGALLY ELIGIBLE TO WORK IN THE UNITED STATES? YES NO HAVE YOU EVER BEEN CONVICTED OF A VIOLATION OF ANY FEDERAL, STATE, COUNTY, AND MUNICIPAL LAW, REGULATION, OR ORDINANCE? YES NO If yes, please list the date and place of the offense, charge, and disposition. Include any convictions as a result of court martials while in the military service. Do not include arrests without conviction or minor vehicle violations for which the only penalty was a fine of $150.00 or less. (the existence of a criminal record does not constitute an automatic bar from employment). PLEASE USE THIS SPACE FOR EXPLANATIONS PERTAINING TO THE ABOVE.</p><p>I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that any misstatement or omission of information is grounds for withdrawal of any employment offer or dismissal from employment.</p><p>I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and I agree to conform to the rules and regulations of Blackburn Law Firm, PLLC.</p><p>I understand and agree that my employment is contingent upon successful completion of a background check and company paid substance abuse test.</p><p>I understand that no manager or representative of Blackburn Law Firm, PLLC, other than the President, may enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.</p><p>I understand and agree that, if hired, my employment is “at will”, for no definite period, and may, regardless of the date of employment of my wages and salary, be terminated at any time without any prior notice.</p><p>I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.</p><p>DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENTS.</p><p>SIGNATURE______DATE______</p>