This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during an interview or on this form are grounds for terminating the application process, or if discovered after employment, terminating employment.

All qualified applicants will receive consideration without regard to any protected status. Hamilton Telecommunications is an equal opportunity employer.

* When would you be available to begin work?

* What category would you prefer?

Full-Time    Part-Time    Temporary    Seasonal

* What schedules are you available?

Weekdays Weekends Evenings Nights Overtime

* Select highest grade level completed

7   8   9   10   11   12   13   14   15   16   16+

	School Name	City / State	Dates	Diploma / Degree
High School
College
Other

* Have you been given a job description or had the requirements explained to you?

Yes   No

* Do you understand these requirements?

Yes   No

* Can you perform the requirements of this job with or without reasonable accommodation?

With   Without

If with, how would you perform the tasks, and with what accommodation(s)?

* Are you authorized to work in this country for any employer?

Yes   No

* Have you worked for Hamilton Telecommunications in the past?

Yes   No

If yes, what division and when?

* Have you ever been convicted of a felony??

Yes   No

If yes, please explain?

---

Please list any additional skills, licenses or certificates you possess which are job related or which you feel may be of value to our company.

Please summarize work experience, starting with your present or most recent employer. Answer all questions completely (any omission may disqualify you from consideration).

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 (MA residents do not answer)
*	*	Start: * End: *
May we contact you at work?
* Yes   No

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 (MA residents do not answer)
		Start: End:

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 (MA residents do not answer)
		Start: End:

Include only those individuals familiar with your work abilities. Do not include relatives.

1.	Name:			Years Known:
	Address:			City:
	State:			Zip Code:
	Telephone Number:			Relationship:
2.	Name:			Years Known:
	Address:			City:
	State:			Zip Code:
	Telephone Number:			Relationship:
3.	Name:			Years Known:
	Address:			City:
	State:			Zip Code:
	Telephone Number:			Relationship:

Please provide any additional comments below:

I hereby certify that the information provided in this application is true, correct and complete. I authorize investigation of all statements contained in this application and I release from liability all persons, companies and corporations supplying such information and agree to indemnify Hamilton Telecommunications against any liability which might result from making such investigation. I fully understand that misrepresentation or omission of facts on this application or other required documents is cause for denial of employment or dismissal if I am employed.

I understand that an offer of employment is contingent upon my ability to establish employment eligibility under the Immigration Reform and Control Act of 1986.

I understand that no contract of employment is created by this application, or by policies and procedures of Hamilton Telecommunications. I agree to comply with the policies and procedures of Hamilton Telecommunications. I understand my employment can be terminated, at the option of either the company or myself.

I have read the above statements. I understand them and I agree with them as conditions of possible employment.

* Signature (type name):

* Date: