In case of emergency, please notify:

If yes, give date and status (i.e. full-time, part-time, temporary)

High School

Undergraduate College

Graduate Professional

Other

Please list all employment since high school in reverse chronological order, starting with your present or most recent job.  Include job-related military service and volunteer activities. You may exclude organizations which indicate race, color, ancestry, religion, creed, gender, national orgin, age, disability, veteran status or any other legally protected status.

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal race, color, ancestry, religion, creed, gender, national orgin, age, disbability, veteran status, or any other legally protected status

List References

I certify that I completed this application and that all of the information given on this application is tru and complete to the best of my knowledge.  I understand that false information, misrepresentation, or omission of information called for on this application may result in denial of employment or subsequent dismissal from employment.

I authorize investigation of all statements contained in this application and release any and all persons, companies, or agencies furnishing such information from any liability for the information they have provided.

I hereby understand and acknowledge that the information provided in this application and the application process itself does not constitute an employment contract with KSM.  I further understand that employment at KSM is employment-at-will and may be terminated by either me or KSM at any time, with or without notice, for any or no reason.  I understand and acknowledge that this application, as well as other communications to me, should not be relied upon by me to my detriment.  Further, I understand and acknowledge that no representative of KSM has authority to alter or change any of the above provisions, except as specifically set forth in a written agreement executed by the President/CEO of Kosei St. Marys.

I also understand that Kosei St. Marys is committed to maintaining procedures that comply with the Drug Free Workspace Act, which prohibits the unlawful manufature, posession, distribution, transfer, purchase, sale, use, and being under the influence of alcoholic beverages or illegal drugs while on the Company's property or while conducting business-related duties or activitis.  I also understand that in support of the Company's Substance Abuse Policy, if I receive an employment offer, I will submit to a drug test, the results of which must be negative in order for my employment to continue.