Colorado Please Print  Application for Employment  Equal access to programs, services and employment opportunities is available to all persons without regard to sex (including pregnancy), race (including traits historically associated with race such as hair texture, hair type, and protective hairstyles), color, religion, national origin, age, physical or mental disability, genetic information, sexual orientation (including transgender status), creed, ancestry, marriage to a co-worker, or Ina accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process; providing written materials in an alternate format such as braille, large print, or audio recording;  any other basis protected by federal, state, and/or local law.  using a sign language interpreter; using specialized equipment; or modifying testing conditions.  Name Address Telephone # Position(s) applied for  Applicant ID#  Last Street  First  Middle City E-mail. Address  State  ZIPCode  Cellular/Other Phone #  Date ofapplication  Referral Source (e.g., Walk-in, Job Posting, Company's Website, etc.).  Ifnecessary, best time to call youi is. Home Cellular/Other May we contact you: at work?.  AM PM Will you relocate ifj job requires it?. Will you travel ifj job requires it?  OYes ONo OYes ONo  OYes ONo Ifthey havel been explained to you, are you ablet to meet the  Ifyes, work number and! bestt timet to call: Ify you are under 18 and iti ist required, can you furnish a work permit. Ifno, please explain:  attendance requirements of thej position?... ON/A OYes ONo  AM PM  Will you work overtime ifi required?. Ifno, please explain:  OYes ONo  ON/A OYes ONo  Have you submitted: an application herel before?. OYes ONo  Ifyes, give date(s) andj position(s): Have you ever been employed herel before?. Ifyes, give dates: From /T Is this application ar request for reemployment following an extended military leave of absence Ifyes, additional information may be requested. Are you lawfully authorized to work int the United States?. Date available for work.  Are you ablet toj perform the" essential functions" of thej jobi for which you are applying (with or without reasonable accommodation) This questioni is not designed to elicit information: about an applicant's disability. Please dor not providei information about the existence ofa disability, particular accommodation, OYes ONo Need more information about the  OYes ONo orv whether accommodation is necessary. These issues may be addressed ata a later stage  tot the extent permitted by law.  jobs" "essential functions" to respond be driving may required State_ Yes ONo  from this company?.  DYes No  Driver's license number required ifc jobi for which you are applying:  in the  Yes ONo Have you ever been bonded?.  Have you entered into an: agreement with any former employer or other party (such as ar noncompetition agreement) that might, ina any way, restrict youra ability tos work for our company/.- Yes ONo  Whati is your desired salary range or hourly rate of pay? Type of employment desired: Full-Time OPart-Time  $.  Per Seasonal  Ifyes, please explain:  Educational Co-Op  Temporary  ANI EQUAL OPPORTUNITY EMPLOYER  Page1    Employment History  Starting with your most recent employer, provide thei followingi information.  Employer Street address Startingi jobt title/final jobt title Why didy youl leave?  Telephone! City  State  Dates employed Month Year Mayw we contact forr reference? E-mail: Dyes ONo Duater  Immediates supervisora andt title (forr mostr recentp position held) Summarizet thet type ofv work performeda andj jobr responsibilities. What didy youl liken most about yourp position? Whaty weret thet things youl likedl leasta aboutt thep position?  Employer Street address Startingj jobt title/finalj jobt title Whyo didy youl leave?  Telephone# City  State Month Year to  Dates employed Month Year Maywec contact forr reference? E-mail: Dyes DNo Duater  Immediate supervisora andt title (forn mostr reçent position held) Summarize thet typec of workp performed andj jobr responsibilities. Whatd didy youl liken mosta abouty your position? Whaty weret thet things youl likedl leasta aboutt thep position?  Employer Street address Startingj jobt title/final jobt title Whyd didy yout leave?  Telephone # City  State to  Datese employed Month Year Mayv wec contact forn reference? E-mail: Dves ONo Dtater  Year  Immediates supervisor and title (forn most recent positionh held) Summarize thet typec ofv work performeda andj jobr responsibilities. Whato didy youl liken mosta abouty yourp position? Whatv were thet things you! liked leasta aboutt thep position?  Employer Streeta address Startingj jobt title/finalj jobt title Whyd didy youl leave?  Telephone# City Dates employed Month Mayw we contact forn reference? E-mail: Dyes ONo Duater  State Month to  Immediate supervisora andt title (forr mostr recent position held) Summarize thet typec ofv workp performeda andj jobr responsibilities. Whato didy you! liken mosta abouty yourp position? Whaty weret thet things youl liked! least about thep position?  Page 2    Employment History (continued)  Explain any gaps in your employment, other than those due toj personal illness, injury, or disability.  Ifnot addressed on previous page, havey you ever been fired or asked to resign from aj job?.  OYes ONo  Ifyes, please explain:  Skills and Qualifications  Summarize any special training, skills, languages, licenses, and/or certificates that may assisty youi inj performing the position forv which you: are applying:  Computer Skills (Include software titles and level ofe experience, such as basic, intermediate, or advanced.)  OWord! Processing OSpreadsheet Presentation E-mail  Level: Level: Level: Level:  Internet DOther DOther, DOther  Level: Level: Level: Level:  Educational Background  Starting with your most recent school attended, provide thef followingi information.  School (include City and State)  Completed #of Years  Completed ODiploma OGED ODegree Certification, DOther ODiploma OGED ODegree OCertification. Dother ODiploma OGED ODegree OCertification. Dother ODiploma OGED ODegree. OCertification. OOther  Class GPA Rank Major/Minor  References  List names and telephone numbers of three business/work references who are not related to you and are not] previous supervisors.  Ifnot applicable, list three school or personal references who are not related to you.  Name  Title  Relationship toYou  Telephone  E-mail  #ofYears Known  )  Page 3    Related Information  When answering these questions, please exclude any information that would reveal sex (including pregnancy), race (including traits historically associated with race: such as hair texture, hair type, and protective hairstyles), color, religion, national origin, age, physical or mental disability, genetici information, sexual orientation (including transgender status), creed, ancestry, marriage to a co-worker, or other similarly protected status.  To whatj job-related organizations (professional, trade, etc.) do you! belong?  List special accomplishments, publications, awards, etc.  List any relevant volunteer work.  Ist there any other job- related information you want us tol know about you?  Applicant Statement  Icertify that alli informationl Ihave provided in ordert toa apply fora and secure work with this employer is true, complete, and correct.  Iexpressly: authorize, without reservation, thee employer, its representatives, employees, or agentst to contact and obtaini information. from all references (personal andp professional), employers, publica agencies, licensing: authorities, ande educationali institutions andt toc otherwise verifyt the accuracyo ofa alli information provided by mei int this application, resumé, orj jobi interview. Ihereby waive any and allr rights and claims Imayh haver regarding the employer, its agents, employees, orr representatives, fors seeking, gathering, and using truthful andr non- defamatoryi information, ina alawful manner, int thee employment process and allo other persons, corporations, or organizations for furnishings suchi information: about me. Iunderstandi that thise employer does noti unlawfully discriminatel in employment andi no question ont this application ist usedf fort thep purposec oflimiting ore eliminatinga any applicant Iunderstandi thatt thisa application remains current for only 60 days. Att thec conclusion oft that time, ifIhaver not! heard fromt thee employer ands stilly wish tob bec considered for IfI: am! hired, understand that Iamf free to resign: at anyt time, with or without cause: and with or without prior notice, and thee employer reservest thes same rightt tot terminate my employment: ata any time, with orv without cause andy witho or without prior notice, except as may ber required! by law. Thisa application does noto constitute an agreement or contract fore employment fora anys specified periodo ord definite duration. Iunderstand thati nos supervisor orr representative of thee employer is authorized to make any assurances tot the contrary andt thatr noi implied oral orv written agreements contrary tot the toregoing expressl language arey validi unless theya arei inv writinga and signedb byt the employer's president. Ialso understand thati ifIa amh hired, Iwillb ber required top provide proofofi identitya andl legala authorization tov worki int thel United Statesa andt that federali immigration laws requirer me Iunderstand that reasonable safeguards willl bet taken top protecta allp personal information provided ord obtainedi in conjunction with this application fore employment. My personal information: may bes sharedy with the employer's affiliate(s): and third parties engaged! by thee employer toj perform servicesf fort thes employer. Any personal information: sharedy with This Company does nott tolerate unlawful discriminationi ini itse employment; practices.) No question ont this applicationi ist used fort the purpose ofl limitingo ore excluding ana applicant from consideration! fore employment ont thel basis ofhis orl hers sex (including pregnancy), race (including traits! historically associated with races sucha ash hair texture, hairt type, andp protective! hairstyles), color, religion, national origin, age, physicald or mental disability genetici information, sexual orientation (includingt transgender Iunderstand that anyi information provided by met that is found tol be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in myi immediate discharge from the employer's service, whenever iti is discovered. Icertify that] Ihave read, fully understand and accept all terms of the foregoing Applicant Statement.  from consideration fore employment ona any basis prohibited bya applicablel local, state, orf federall law. employment, ity willl ber necessary for met to reapply and fllo outa a new application.  toc complete anl I-9F Formi int this regard.  ana affiliate ort third partyi ist tob bet used: solely top perform thes services requested! by thee employer.  status), creed, ancestry, marriage toac co-worker, ora any other protected status under: applicable federal, state, orl locall law. DOI NOT SIGN UNTIL YOUI HAVEI READ' THE ABOVEAPPLICANT STATEMENT.  Signature of Applicant  Date.  Thisp productis is designed top providea accurate anda authoritativei information, However, itisnota substitute forl legala advice: andu does not provide legal or distributingt thisp productisr notl liable for: anyd damages arising outo oft theu useori inabilityt tou usetl thisp product. Youa areu urged! to consult: ana attorney concerningy yourp particulars situation: anda anys specific questions ord concernsy youn mayk have. Importantn note:7 Thisi isapprovedf foru useb byt thep purchaser only." Thisf formr mayr notb bes sharedp publiclyo ory witht thirdp parties.  COMPLYRIGHT opinionso ona anys specific factso or services. Thei informationi isp provided witht thet understanding thata any persono ore entity involvedi inc creating.p producing  020200 ComplyRight,Inc. A2179_CO  ATTORNEY  Page 4