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Application for Independent Representative *

Shinn Spring Water Company

We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.

We are an Equal Opportunity Employer.

PERSONAL INFORMATION:
Applicant Name (First, Middle, Last):
Street Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Email:

Have you ever been previously employed by our organization?	Yes	No
Are you legally eligible for employment in the United States?	Yes	No
If you are under 18, can you furnish a work permit if it is required?	Yes	No

EMPLOYMENT DESIRED:
Position(s) applied for or type of work desired:
Specific Available Hours: (Full-time, part-time, temporary)
Salary Desired:
Date you can start:
How were you referred to us?:
Have you ever been convicted of a crime in the last 7 years?	Yes * No
* If yes, please explain (a conviction will not automatically bar employment)?:

EMPLOYMENT HISTORY:
Please List your last 3 employers, starting with the most recent:
Most Recent Employer
Name of Employer:
Position Held:
Address:
Phone Number:
Immediate Supervisor's Name and Title:
May We Contact Your Supervisor?	Yes No
Dates of Employment:	From to
Salary/Wage:
Reason for Leaving:
Previous Employer
Name of Employer:
Position Held:
Address:
Phone Number:
Immediate Supervisor's Name and Title:
May We Contact Your Supervisor?	Yes No
Dates of Employment:	From to
Salary/Wage:
Reason for Leaving:
Previous Employer
Name of Employer:
Position Held:
Address:
Phone Number:
Immediate Supervisor's Name and Title:
May We Contact Your Supervisor?	Yes No
Dates of Employment:	From to
Salary/Wage:
Reason for Leaving:

EDUCATION:
High School:
Name of School
Location of School
# of Years Attended
Did you Graduate	Yes No
Subjects Studied/Degrees Received
Trade, Business, Technical School
Name of School
Location of School
# of Years Attended
Did you Graduate	Yes No
Subjects Studied/Degrees Received
College
Name of School
Location of School
# of Years Attended
Did you Graduate	Yes No
Subjects Studied/Degrees Received
Other
Name of School
Location of School
# of Years Attended
Did you Graduate	Yes No
Subjects Studied/Degrees Received

OTHER SKILLS AND QUALIFICATIONS:
Summarize any job-related training, skills, licenses, certificaties, and/or other qualifications:

REFERENCES:
Please give the names of three individuals whom you have known for at least one (1) year. NO relatives please.
Name	Occupation/Title	Telephone	Years Known

Shinn Spring Water Company:

2 East Pointe Drive
Birdsboro, PA 19508

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either the employer or I can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall in immediate termination of employment.

* This form may also be used by Shinn Spring Water Company for the purposes of gathering information from potential independent contractors and is not to be construed to establish or infer an employer-employee relationship within the meaning of applicable law(s).

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Name/Signature: Date: 7/31/2010

Verification Code:*

Please input the numbers you see into the box below. No spaces are necessary.

Shinn Spring Water Company - 2 East Pointe Drive, Birdsboro, PA 19508
Local: (610) 478-0300 - Toll Free: (800) 924-6841 - Fax: (610) 288-2071