Personal Information

Name:
Address:
Former/Maiden Name:		Have you ever been convicted of a felony?	No Yes
Home Phone:		Work Phone:
How did you learn of us?
If you were referred, who referred you?

Position Desired

Position Applying For:
Pay Expected ($):	Per
Do you prefer? (check all that apply)	Full Time or Part Time 1st Shift or 2nd Shift
Would you consider seasonal?	No Yes

General Information

Have you ever worked at InterDesign?	No Yes	If yes, list dates:
Have you ever applied to InterDesign before?	No Yes	If yes, list dates:

Education

Level	Name of School	City, State of School	Major	Minor	Completion	GPA (if known)	Degree
High School			N/A	N/A	Diploma GED None		N/A
Vocational School					Certificate
College					0 years 1 year 2 years 3 years 4 years
College					0 years 1 year 2 years 3 years 4 years

Employment History (most recent first)

Employer:				Phone:
Address:
Date Started:		Date Ended:		Position:
Name of Last Supervisor:			Salary ($):	Per
Reason for Leaving:
Briefly Describe your Responsibilities:
May we contact?	No Yes

Employment History (most recent first)

Employer:				Phone:
Address:
Date Started:		Date Ended:		Position:
Name of Last Supervisor:			Salary ($):	Per
Reason for Leaving:
Briefly Describe your Responsibilities:
May we contact?	No Yes

Employment History (most recent first)

Employer:				Phone:
Address:
Date Started:		Date Ended:		Position:
Name of Last Supervisor:			Salary ($):	Per
Reason for Leaving:
Briefly Describe your Responsibilities:
May we contact?	No Yes

References (Please list the names of individuals not related to you who have knowledge of your work performance)

Name:		Phone:
Relationship to you:
Name:		Phone:
Relationship to you:
Name:		Phone:
Relationship to you:

The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex, or national origin. Some States prohibit discrimination because of age. The Age Discrimination In Employment Act of 1967 as amended prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. If this State prohibits the request of any information on this form, this information will not be sued to discriminate against possible employment.

Comments (Please list any other experience or training you have that we should consider when reviewing this application)

The information provided by me on this application is true and complete. I have not knowingly falsified or withheld any facts which, if disclosed, would adversely affect my application. I understand that any such falsification or withholding, no matter when discovered, could disqualify me from further consideration as a candidate for employment with InterDesign or be grounds for termination if I am employed. I have, by submitting this application, authorized InterDesign to investigate my background in order to evaluate my qualifications and to verify information contained in my resume and/or application. If I become employed by InterDesign, I understand that I will be bound by all its policies and procedures. I understand that any job offer is subject to InterDesign obtaining favorable references from prior employers and my ability to establish employment eligibility under the Immigration and Reform Act of 1986. I have read, understand, and agree to the above conditions of employment. If I become an employee of InterDesign I understand I will be an employee at-will which means that I have the right to terminate my employment at any time, and that InterDesign has the same right to terminate my employment, with or without cause, and with or without notice, at any time. I authorize deduction from my pay of any indebtedness to the Company.

I have read and agree to the above terms.