Draper Imaging Group

Employment Application

Please fill out and submit the application below if you'd like to be considered for employment.

Only fully completed applications will be considered.

Personal Information

Applicant Name:

Street Address:

City: State: ZIP:

        Mailing Address:
          (If different than street address.)
        City:   State:     ZIP:

Phone (w/area code): Email:

1. Are you 18 years of age or older? Yes No If under 18, state age:

2. Are you legally eligible to work in the United States? Yes No
If hired, you must be able to present evidence of your U.S. citizenship or proof of your legal right to work in the U.S.

3. Have you ever been convicted of, or pled no contest to, a crime? Yes No
     If yes, please explain nature of the offense, when it occurred, and disposition of sentence:

        (If more than one, explain circumstances of each.)

Position for which you are applying:

Employment History

May we contact your current employer? Yes No

Please list work experience, most recent first:

1. Employer: Reason for leaving:

Dates of employment: From To

Position/Duties:

2. Employer: Reason for leaving:

Dates of employment: From To

Position/Duties:

3. Employer: Reason for leaving:

Dates of employment: From To

Position/Duties:

4. Employer: Reason for leaving:

Dates of employment: From To

Position/Duties:

Education & Training

Please list education experience, most recent first:

1. School: Number of years attended:

Degree, diploma or certificate earned:

2. School: Number of years attended:

Degree, diploma or certificate earned:

3. School: Number of years attended:

Degree, diploma or certificate earned:

Please describe any other training that may enhance your qualifications for this job:

Please list professional organizations to which you belong:

Is there anything else you'd especially like us to know in considering you for this position?

I certify that I am the person named in this employment application. I attest to the fact that the answers given by me are true and correct to the best of my knowledge. I understand that any omission or misstatement of fact on this application or on any document used to secure employment can be grounds for rejection of application or, if I am hired, cause for immediate termination of employment. Yes No

I permit the company to examine my record of employment, education record, and any other information I have provided for reference. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. I release Draper Imaging Group, my former employers and all other parties from any and all claims or liabilities arising out of such examination. Yes No

In lieu of a written signature, please type your initials: