Answer each question fully and accurately. No action will be taken on this application until you have answered all questions. Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for your signature on the back of application. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.     First Name Middle Initial Last Name Telephone   Present Address City State Zip How long have you lived at this address? _________________________ When could you start? ____________________   Are you 18 years of age? _____ Yes _____ No What job are you applying for? ____________________________________________ Are you seeking? _____ Full-Time _____ Part-Time _____ Week-end Only _____ Temp. Is there any day/days and times you cannot work? List: ______________________________ What times can you work? _____________________________________________________ Have you ever applied here before? __ Yes __ No Have you worked here before? __ Yes __ No Have you ever been convicted of any law violation? _____ Yes _____ No (Include any plea of "guilty" or "no contest." Exclude minor traffic violations.) If yes, give details ______________________________________________________________ (A conviction will not necessarily disqualify you for employment.) If hired, do you expect to engage in any additional business, school or employment outside of Lazer Force? _____ Yes _____ No If yes, give details? ______________________________________________________ Do you have a driver’s license? _____ Yes _____ No    If yes, state issued? ____________ Are you a US Citizen? _____ Yes _____ No (If no, you will have to furnish proof you are eligible to work in the US.) Have you had a Hepatitus A shot? _____ Yes _____ No (You must have one if hired.) Are you able to clearly distinguish different colors? _____ Yes _____ No

EDUCATION List the name and city of school attended. # of years completed Diploma / Degree Subjects studied High School or GED: ____________________________________________________________ College or University: ____________________________________________________________ Vocational or technical: __________________________________________________________ Any additional skills or training that you may have: _____________________________________ _____________________________________________________________________________

PREVIOUS EMPLOYMENT List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. Note: A job offer may be contingent upon acceptable references from former employers. Your previous employers will be contacted. We welcome first job applicants. Employer's Name: __________________________  Job or duties: ________________________ Address: ________________________________ City, State, Zip: ________________________ Dates of employment (mo/yr): From: _____ To: _____ Pay: Start: $_______ Ending: $________ Supervisors: _________________________________ Telephone #: ______________________ Reason for leaving: _____________________________________________________________ Employer's Name: __________________________  Job or duties: ________________________ Address: ________________________________ City, State, Zip: ________________________ Dates of employment (mo/yr): From: _____ To: _____ Pay: Start: $_______ Ending: $________ Supervisors: _________________________________ Telephone #: ______________________ Reason for leaving: _____________________________________________________________ Employer's Name: __________________________  Job or duties: ________________________ Address: ________________________________ City, State, Zip: ________________________ Dates of employment (mo/yr): From: _____ To: _____ Pay: Start: $_______ Ending: $________ Supervisors: _________________________________ Telephone #: ______________________ Reason for leaving: _____________________________________________________________ Employer's Name: __________________________  Job or duties: ________________________ Address: ________________________________ City, State, Zip: ________________________ Dates of employment (mo/yr): From: _____ To: _____ Pay: Start: $_______ Ending: $________ Supervisors: _________________________________ Telephone #: ______________________ Reason for leaving: _____________________________________________________________

PERSONAL REFERENCES Your personal references will most likely be called. Please be accurate. If you are under 18 please list only the ones asked on each line. Name Relationship To You # Years Known Phone Number Parent Teacher Other Adult PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING I certify that all information provided in this employment application is true and complete. I understand that any false information or omissions may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school or past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organization from any legal liability in making such statements. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand that this application, verbal statements by management, or subsequent employment does not create an express or implied contract of employment nor guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time with reason and with or without notice. I have read, understand, and by my signature consent to these statements.

Signature: _________________________________________    Date: ____________________
This application for employment will remain active for six months and then will be shredded and discarded.

Return Application to:

LAZER FORCE, INC., 50 TUCKER DRIVE, CASEYVILLE, IL 62232, 618-397-0677