* Golden West does not sponsor work visas for new or existing employees. Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment).:

Yes   No

* Are you at least 18 years or older?:

Yes   No

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes   No

If no, please explain:

* Have you ever worked for this Company before?:

Yes   No

If Yes, please provide details (Where/When/Job Title):

* Are you related to any current Golden West employees and/or directors?:

Yes   No

If yes, name and relationship:

* Were you referred to apply for this position by any Golden West customer?:

Yes   No

If yes, full name, address, town and phone number of customer.:

* Have you ever pleaded 'guilty' or 'no contest' to, or been convicted of, a crime? (A conviction will not necessarily result in the denial of employment):

Yes   No

If Yes, please explain:

* Do you have a current driver's license?:

Yes   No

* When would you be available to begin work?:

* Hourly rate/salary desired:

* Are you currently employed?:

Yes   No

If so may we inquire of your present employer?:

Yes   No

If presently employed, why are you considering leaving?:

Would you accept full-time work?:

Yes   No

Would you accept part-time work?:

Yes   No

Will you travel if required:

Yes   No

Will you work overtime if required:

Yes   No

Have you entered into an agreement with any former employer or other party (such as a non-compete/non-solicitation agreement) that might, in any way, restrict your ability to work for Golden West?:

Yes   No

If Yes, please explain:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate?	Degree Received	Subjects Studied/Major
	Yes   No
	Yes   No
	Yes   No

Computer Skills (Check appropriate boxes. Included software titles and years of experience.)

	Software Title(s)	Years of Experience
Word Processing
Spread Sheet
Presentation
E-Mail
Internet
Other
Other
Other

Give your full employment record, starting with your current or most recent employment

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
What did you like most about your position?	What did you like least about your position?

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
What did you like most about your position?	What did you like least about your position?

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
What did you like most about your position?	What did you like least about your position?

Explain any gaps in your employment, other than those due to personal illness, injury or disability.:

* If not addressed above, have you ever been fired or asked to resign from a job?:

Yes   No

If yes, please explain:

Name	Relationship	Phone Number	Email

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.

If hired, I agree to conform to the Company's rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either express or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or the Company's option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company. I understand that no Company representative, other than its General Manager/CEO, and then only when in writing and signed by the General Manager/CEO, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

I also understand that, if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States as required by federal immigration laws. I will be required to complete an Employment Eligibility Verification, Form I-9.

This Company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local law. No question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law.

* Signature (type name):

* Date: