Name: Last First Middle
Phone (include area code)	Social Security No.
Address City State ZIP
E-Mail Address	Position applying for

LIST YOUR EMPLOYMENT RECORD FOR LAST 10 YEARS (LIST LAST POSITION FIRST) - UNEMPLOYMENT PERIODS MUST BE LISTED WITH NAMES AND ADDRESSES OF 2 PERSONS WHO CAN CONFIRM THEM. IF NO FORMER EMPLOYMENT, LIST 3 CHARACTER REFERENCES.

#1	MONTH/YEAR BEGAN	MONTH/YEAR LEFT	COMPANY'S NAME	STREET, CITY AND STATE

FOR WHOM WORKED	POSITION HELD	REASON FOR LEAVING

#2	MONTH/YEAR BEGAN	MONTH/YEAR LEFT	COMPANY'S NAME	STREET, CITY AND STATE

FOR WHOM WORKED	POSITION HELD	REASON FOR LEAVING

#3	MONTH/YEAR BEGAN	MONTH/YEAR LEFT	COMPANY'S NAME	STREET, CITY AND STATE

FOR WHOM WORKED	POSITION HELD	REASON FOR LEAVING

#4	MONTH/YEAR BEGAN	MONTH/YEAR LEFT	COMPANY'S NAME	STREET, CITY AND STATE

FOR WHOM WORKED	POSITION HELD	REASON FOR LEAVING

#5	MONTH/YEAR BEGAN	MONTH/YEAR LEFT	COMPANY'S NAME	STREET, CITY AND STATE

FOR WHOM WORKED	POSITION HELD	REASON FOR LEAVING

If currently employed, may we contact your employer? Yes \| No	If hired, can you provide documents required to prove you are legally able to work in the United States? Yes \| No
State age if under 18	Can you perform all the job functions of the position(s) for which you are applying, with or without a reasonable accommodation? Please describe the accommodation you need, if any.
Are you a high school graduate? Yes \| No \| GED
Have you ever been convicted of a felony or are there any felony charges pending against you? If yes, please explain.	Are you related to any past or present employees of Peerless Mattress and Furniture, Co.? If so, please list names of such employees.
Are you available for work: Full Time \| Part Time

PLEASE READ Peerless Mattress and Furniture, Co. is an equal opportunity employer and complies with all laws prohibiting discrimination on the basis of race, color, age, sex, national origin, religion, citizenship, handicap, height, weight and marital status. Under the Michigan Handicapper's Civil Rights Act, an employer has a legal obligation to accommodate an employee's or job applicant's handicap unless the accommodations would impose an undue hardship on the employer. A handicapper may allege a violation against an employer regarding a failure to accommodate his or her handicap under that law only if the handicapper notifies the employer in writing of the need for accommodation within 182 days after the date the handicapper knew or reasonably should have known that an accommodation was needed. I certify that information given in this Application is true and complete to the best of my knowledge. I understand that Peerless Mattress and Furniture, Co. (Peerless) may investigate my work and personal history and verify all data given on this Application, on related papers, and in interviews. I authorize all individuals, schools and employers named therein, except as specifically limited on this Application, to provide information requested about me, and I release them from liability for damages in providing this information. I understand and acknowledge that any misrepresentation or omission of fact can result in immediate discharge.