Employment Application Form Application Information:

Applicant Name: Lane (Last) Hadiyyah (First) Sahar (Middle)

Home Phone: (334) 875-2352 Other:______________ Email Address: gift.love@gmail.com 840 County Road 261 Jones Al., 36749 (Address) (City) (State) (Zip) How were you referred to Company?__________________

Employment Positions
Position(s) applying for:_______________

Are you applying for:

Temporary work- such as summer or holiday work? [*]Y or [ ]N Regular part-time work? [ ]Y or [ *]N Regular full-time work? [* ]Y or [ ]N

What days and hours are you available to work? 11 a.m.- 9 p.m. If applying for temporary work, when will you be available?____________ If hired, on what date can you start working? 11/15/13 Can you work on the work on the weekends? [* ]Y or [ ]N Can you work evenings? [* ]Y or [ ]N Are you available to work overtime? [ *]Y or [ ]N Salary desired: $________________

Personal Information:
Have you ever applied to/worked for Company before? [ ]Y or [* ]N If yes please explain (include date):__________

Do you have any friends, relatives, or acquaintances working for Company? [ ]Y or [ *]N If yes, state name & relationship:___________________ If hired, would you have transportation to/from work? [ *]Y or [ ]N Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.) [ ]Y or [ *]N If hired, would you be able to present evidence of you U.S. citizenship of proof of your legal right to work in the United States? [* ]Y or [ ] N If hired, are you willing to submit to and pass a controlled substance test? [ *]Y or [ ]N Are you able to perform the essential functions of the job for which you are applying, either with/without reasonable accommodation? [ *]Y or [ ]N If no, describe the functions that cannot be performed______________ Have you ever been convicted of a criminal offense (felony or misdemeanor)? [ ]Y or [* ]N If yes, please describe the crime- state nature of the crime(s), when and where convicted and disposition of the case.______________________________

Education, Training and Experience

High School: School name: Dallas County School School: 335 Fifth Avenue Plantersville Al., (Address) (City) (State) Number of years completed: 2011-2015

36701 (Zip)

Did you graduate? [*]Y or [ ]N School Graduation Diploma

Degree/diploma earned: High

College/University:
School name: University of Alabama School: 719 University Blvd Tuscaloosa AL 35401 (Address) (City) (State) (Zip) Number of years completed:____________ Did you graduate? [*]Y or [ ]N Degree/ Diploma earned:_______________

Vocational School:
Name:_________________ School:________________________________________________________ ____________ (Address) (City) (State) (Zip) Number of years completed:____________ Did you graduate? [ ]Y or [ ]N Degree/diploma:___________________

Military
Branch:______________ Rank in Military:_____________________ Total years of service:___________ Skills/duties:_________________________ Related details:_________________________________ Do you speak, write, or understand foreign languages? [ ]Y or [ ]N If yes, describe which language(s) and how fluent of a speak you consider yourself to be:___________________________________________________________ ______________

Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in case that they make you especially suited for working with you? [ ]Y or [ ]N If yes, please explain:______________________________________________

Employment History
Are you currently employed? [ ]Y or [*]N If you are currently employed, may we contact your current employer? [ ] Y or [ ] N

Below, please describe past and present employment positions, dating back five years. Please account for all periods of unemployment. Even if you have attached a resume, this section must be completed. Name: Anna Williams (Employer ) Telephone number: (334) 873-4576 David Mosley (Supervisor) Business type:

756 County Road 124 Selma Al. 36752 (Address) (City) (State) (Zip) Length of employment (Include dates): 8 months. Jan. 5- Dec. 12. 2011 Position & Duties: Cashier Reason for leaving: Applied for another job May we contact the employer for references? [ *]Y or [ ]N

Name: Lyn Morgan (Employer ) Telephone number: (334) 543-2341 42 County Road 123 (Address) Marion Junction (City)

Christian Bale (Supervisor) Business type:_________________ Al., (State) 36475 (Zip)

Length of employment (Include dates): Jan.23-Aug.22. 2012 Position & Duties: Stacked up items Reason for leaving: Pay wasnt good enough May we contact the employer for references? [*]Y or [ ] N

Name: Luke Marvin (Employer ) Telephone number: (334) 875-9483

Dee Jones (Supervisor) Business type:_________________

1231 Bird Street 12 Selma Al., 37664 (Address) (City) (State) (Zip) Length of employment (Include dates): Sept. 13-Jan. 5. 2012 Position & Duties_______________________________________________________ Reason for leaving:_____________________________________________________ May we contact the employer for references? [ ]Y or [ ]N

Reference
List below 3 people who have knowledge of your work performance within the last 4 years. Please include professional references only. 1. Name: Vera Lane (First) (Last) Address: 564 County Rd. 908 Occupation: Surgeon 2. Name: Telephone: (334) 234-2341 59347 (Zip)

Selma Al. (City) (State) Number of years acquainted: 5

Sue Beal (First) (Last) Address: 234 Lake Drive 214

Telephone: (334) 453-5678 33697 (Zip)

Occupation: Doctor 3.

Selma AL. (City) (State) Number of years acquainted: 2

Name: Stan Lee (First) (Last)

Telephone: (334) 345-2565

Address: 453 Conner Av. 587 Occupation: RN

Jones Al. 36714 (City) (State) (Zip) Number of years aquatinted: 6

Please read and initial each paragraph, then sign below I certify that I have not purposely withheld and information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that nay omission (including any misstatement) of material fact on this application or on any

document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for immediate expulsion from the company. HL I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company. HL I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to may work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers & all other persons, corporations, partnerships & associations from any & all claims, demands or liabilities arising out of or in any way related to such examination or revelation. HL Applicants Signature:_______________________ Date:____________________