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Lakeland Office
1643 Williamsburg Square

Lakeland, FL 33803

voice 863.802.9675

fax 863.646.3050

Tampa Office
655 North Franklin Street
Suite 900
Tampa, FL 33602
800-418-2091

Mailing Address:
PO Box 7164
Winter Haven, FL 33883

EMPLOYMENT

* Indicates required field
Personal Information
First Name *	Last Name *
Address 1 *	Address 2
City *	State *
Zipcode *	Phone (with area code) *
Email *
Employment Desired
Position you are applying for? *	What is your desired hourly pay?
Full Time Part Time Either	Permanent Temporary Either
If hired, on what date can you start?	Check if you are under 18 years of age (hire is subject to verification that you are of legal age)
Do you have the legal right to work in the United States? Proof of identity and legal authority to work in the United States is a condition of employment
Have you ever been convicted of a crime other than a minor traffic violation? (Note a conviction will not automatically disqualify you. Each case will be individually considered.) Yes No
If you answered Yes to the above, please state the nature of the crime, when and where convicted and the disposition of the case

I hereby certify that the information contained in this application is true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any misrepresentation, falsification or omission of information in my applications, or on any document used to secure employment, shall be grounds for rejection of this application or immediate discharge if I am employed, regardless of the time elapsed before discovery. I hereby authorize the Company to thoroughly investigate my background, the information on my application, my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the Company all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons or entities from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosures. The Company adheres to a policy of at-will employment which recognizes that each employee and the Company each retain the right to terminate the employment relationship and that the Company retains the right to modify an employees position or compensation at any time, with or without cause or notice. No one other than the President has the authority to make any binding promise or enter into any agreement inconsistent with the Companys at-will policy and any such agreement must be in writing and signed by both parties to be effective. As a condition of employment, all individuals offered employment may be required to submit to a pre-employment drug test. If you agree to the certifications above, check each check box and enter your first and last names below.

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