Last Name First Name Middle Name

Are you under age 18?                           Area Code/Phone #

E-mail address:

Full Address Describe type of employment you desire

Expected pay rate $ per (hour, month, or year)

Have you ever worked for POM before? If so, when?

Have you ever used or been known by a name other than entered above? If so, what?

EDUCATION:

High School (name, city, state) Grade Completed

College(s) Courses or Major Hours or Degree

Business, Trade, Apprentice, Correspondence or Military (describe):

Are you pursuing a course of study now?

If so, indicate course, name and location of institution:

SKILLS --Please indicate skills or equipment capable of performing or operating:

REFERENCES -- List two persons who have known you for more than five years (exclude former employers or relatives):

EMPLOYMENT -- List all employment for the past ten years, including military service and self-employment (account for all periods of unemployment)

Present or Most Recent Employer Name/Address Base wage/salary $ per (hour, month, year)

Date: From To Job Title

Supervisor's Name Reason for Leaving

Describe major job duties:

If presently employed, may we contact your employer for references? (check if yes)

May we contact you at your place of employment?   Phone (with area code)

Employer Name/Address Base wage/salary $ per (hour, month, year)

Date: From To Job Title

Supervisor's Name Reason for Leaving

Describe major job duties:

Employer Name/Address Base wage/salary $ per (hour, month, year)

Date: From To Job Title

Supervisor's Name Reason for Leaving

Describe major job duties:

U.S. MILITARY SERVICE -- Branch   Initial Rank

Final Rank Specialty

Do you have any impairment (physical, mental, or medical) which would prevent you from performing in a reasonable manner the activities involved in the job or occupation for which you are applying?    Check if yes

Explain

Have you ever been convicted of a felony?  Check if yes.  Explain

PERSONAL -- List all your residence address for the past five years.  If you were in the U.S. Armed forces, list those just prior to entering, if within the past five years.

Remarks: 

By submitting this application, I hereby certify that the answers given by me to the foregoing questions and statements are true and correct, without mental reservations of any kind whatsoever, and hereby authorize POM Incorporated to verify same.  If employment is obtained under this application, I will comply with all orders, rules and regulations of the company.  I agree to submit to physical examination, which includes drug testing.  I also authorize my former employers and educational institutions to give any information they may have regarding me.  I hereby release them and their organizations from all liability for any damage whatsoever for issuing same.  If upon investigation, anything contained in this application is found to be untrue, I understand I will be subject to dismissal at any time during the period of my employment.  I understand I would be employed at this company at my own will and the company makes me no promises.  This application will remain active for three months.

  If a Frontpage error occurs after you choose "Submit", print this form and fax to 479-968-2840, attn: Stephanie Pendergraft