Application for Employment USH Application for Employment Personal InformationToday's Date: Name:* First Middle Last Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone:*Mobile Phone:*Email:* Are you under the age of 18?* yes no Do you possess a valid work permit?* yes no Last 4 digits of your social security number:* Are you currently authorized to work in the United States?*Proof of eligibility will be required if hired yes no Have you ever been employed by USHydrations, formerly Nature's Way Purewater?* yes no What was the start date of your last employment with us?* MM slash DD slash YYYY What was the end date of your last employment with us?* MM slash DD slash YYYY Are you related to anyone currently employed by us?* yes no Who are you related to?* First Last How are you related?* Position you are applying for:* How did you hear about this opportunity?*NewspaperInternetOtherEmployee referralWho made you aware of this opening?* First Last Desired Annual Salary:*When are you available to be begin work?* MM slash DD slash YYYY What type of position are you interested in?*check all that apply Full time Part time Temporary/Seasonal What best describes your availability to work?*Occasional overtime and weekends will be mandated and requiredI can work any hours / any daysI can only work specific days and timesWhat days can you work?*Check all that apply Monday Tuesday Wednesday Thursday Friday Saturday Sunday What time can you start Monday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time do you need to stop Monday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time can you start Tuesday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time do you need to stop Tuesday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time can you start Wednesday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time do you need to stop Wednesday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time can you start Thursday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time do you need to stop Thursday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time can you start Friday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time do you need to stop Friday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time can you start Saturday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time do you need to stop Saturday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time can you start Sunday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMWhat time do you need to stop Sunday?12:00 AM1:00 AM2:00 AM3:00 AM4:00 AM5:00 AM6:00 AM7:00 AM8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PM9:00 PM10:00 PM11:00 PMHave you ever been assigned to work at USHydrations, formerly Nature's Way Purewater through a staffing agency?* yes no What was the agency's name?* When did your assignment start?* MM slash DD slash YYYY When did your assignment end?* MM slash DD slash YYYY What type of work did you perform during your assignment?* Have you ever signed a non-compete of confidentiality agreement prohibiting you from accepting employment with a company like USHydrations?* yes no Explain the terms of the agreement:*Today do you have an active Pennsylvania driver's license in good standing?* yes no Can you explain the reason for your license standing?*Do you have any moving violations, accidents, or were your driving privileges suspended during the past 3 years?* yes no Can you explain the violations, accidents, and/or suspension?*In the last seven (7) years have you been charged or convicted of ANY misdemeanors or felonies?* yes no Are these charges or convictions substantially related to the functions of the position for which you are applying?* yes no What was the date of the conviction?* MM slash DD slash YYYY What was the nature of the offense?*Where did the conviction occur?* What was the disposition of the case?*Military ExperienceHave you ever been an enlisted member of the United States armed forces?* yes no What branch did you serve in?*Air Force / Air Force ReserveAir National GuardArmy / Army ReserveArmy National GuardCoast Guard / Coast Guard ReserveMarine Corps / Marine Corps ReserveNavy / Navy ReservePlease list any relevant skills/work experience you acquired during your military service:*Employment HistoryPlease list your present or most recent job first and include all employment experiences in the past seven (7) years.Most recent employer:* Company phone:*Job Title:* Start date of employment:* MM slash DD slash YYYY End date of employment:* MM slash DD slash YYYY Supervisor:* What was your starting hourly rate?*What was your final hourly rate?*Reason for leaving:*Please be specificMay we contact this employer?* yes no Are you able to provide information for a second employer?Please select an optionYesI have no additional employers.Second most recent employer:* Company phone:*Job Title:* Start date of employment:* MM slash DD slash YYYY End date of employment:* MM slash DD slash YYYY Supervisor:* What was your starting hourly rate?*What was your final hourly rate?*Reason for leaving:*Please be specificMay we contact this employer?* yes no Are you able to provide information for a third employer?Please select an optionYesI have no additional employers.3rd Most recent employer:* Company phone:*Job Title:* Start date of employment:* MM slash DD slash YYYY End date of employment:* MM slash DD slash YYYY Supervisor:* What was your starting hourly rate?*What was your final hourly rate?*Reason for leaving:*Please be specificMay we contact this employer?* yes no Other experience and qualifications:*Please use this space to elaborate on your background, experience or qualifications that you believe should be considered in evaluating your qualifications for employment.Educational backgroundWhat kind of educational background do you have?* No GED or High School Diploma GED High school College Trade school Check all that applyName & location of school you received your GED from:* Number of years completed:*Did you graduate?* yes no Degree/Diploma Type:* Where did you attend high school?* Number of years completed:*Did you graduate?* yes no Degree/Diploma Type:* Where did you attend college?* How many years of college did you complete?*Did you graduate?* yes no What type of degree(s) do you have?*Name & location of trade school:* Number of years completed:*Did you graduate?* yes no Degree/Diploma Type:*ReferencesPlease list two (2) professional references and one (1) personal reference other than a relative.1st Reference:* First Last Company & Position:* Phone:*Years known:*Second Reference:* First Last Company & Position:* Phone:*Years known:*Third reference:* First Last Relationship:* Phone:*Years known:*Resume Upload:Accepted file types: pdf, , Max. file size: 56 MB.AcknowledgementPLEASE READ CAREFULLY We are an EEO employer. USHydrations adheres to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age or disability. APPLICATION ACKNOWLEDGEMENT I submit this application freely and willingly as a gesture of my interest in employment. I declare the information I provided herein is true, complete and represents an accurate statement of facts. If hired, I agree to abide by all policies and rules whether written, verbal or otherwise during my course of employment. If selected I will be employed on an “at will” basis and either I or my employer will have the right to end our employment relationship at any time with or without notice or for any or no reason whatsoever. I understand USHydrations has a drug free workplace and reserves the right to conduct pre-employment and random drug testing if I am hired. I understand any offer of employment or continued employment is not guaranteed for any length of time. I authorize an investigation of all statements contained in this application now and during the course of my employment. I understand that any misrepresentation or omission of facts is cause for dismissal at any time without any previous notice. Any corrections I wish to make to the information included herein must be submitted in writing. I hereby give USHydrations or their assigns full permission to contact schools, all previous employers (unless otherwise indicated), references and others and hereby release the Company from any liability as a result of such contract or references on my behalf.Digital Signature:*The boxes below represent your digital signature, and by typing your name within them you acknowledge and agree with the above statements. First Last Today's Date: