Education:

Employment History: List current/former employers, most recent first.

History of Unemployment:

Please list any periods of more than one month since you left school or during the last ten years during which you were not unemployed.

Performance of Job Related Functions:

Are you able to perform the functions of the job for which you are applying with or without accommodation? Yes No

Do you take any illegal drugs? Yes No
If yes, describe fully:

Do you use alcohol? Yes No If yes, do you drink to the extent that you would be prevented from performing the essential functions of your job for which you are applying with or without a reasonable accommodation? Yes No If yes, describe fully your use of alcohol:

If requested, are you available to work:
weekends evenings days overtime

Criminal Matters:

Have you ever been convicted of (or pleaded guilty or nolo contendere to) a crime? Do not identify convictions (or guilty or nolo contendere pleas) for which the criminal record has been expunged, sealed or eradicated by the court, or misdemeanor convictions for which any probation has been completed and the case dismissed by the court.

Yes No

Number of times

Did any convictions or pleas result in your imprisonment?

Yes No

Number of times

Explain each conviction fully (or guilty or nolo contendere plea). A conviction or a plea will not neccessarily disquality an applicant.


Have you ever committed a crime?

Yes No

Number of times

If yes, explain fully: (Commission of a crime will not necessarily disqualify an applicant).


Are you currently charged with an unresolved criminal charge which has not yet resulted in a plea, a trial, or a droping of the charge, or for which you are out on bail or on your own recognizance pending trial? Yes No
A charge will not necessarily disqualify an applicant.
If yes, explain fully:

Service Record:

Branch of military: Enter date: Discharge date:

References:

Please provide the names of three persons you have known for more than one year who are not related to you.
NAME, ADDRESS, and PHONE




Talley Inc. is an Equal Opportunity Employer. It is the policy of Talley, Inc. from recruitment through employment and promotion and in any decision termination of employment, to provide an equal opportunity to each employee at all times without regard to race, color, religion, sex, age, national origin, martial status, sexual orientation, political belief, physical disability or history of mental disorders (except where physical or mental abilities are a bona fide occupational requirement).

AUTHORIZATION - IMPORTANT

PLEASE READ CAREFULLY BEFORE SIGNING.

I declare under penalty of perjury that the facts contained in this application in this application or any resume or other documentation submitted by me are true and complete to the best of my knowledge. I understand that any falase information or significant omissions will disqualify me from further consideration for employment, and will be justification for my dismissal from employment if discovered at a later date.

I agree to immediately notify the company if I should be convicted of any crime while my job application is pending or during my period of employment, if hired.

I authorize the investigation of all statements contained in this application and any accompanying documentation provided by me and further authorize any person, employer (except as expressly noted to the contrary), and organization identified in this application form to provide the company with records, information and opinion that may be useful in making a hiring decisioni. I release all informants from all liability for any damage that may result from furnishing information and opinoin to you provided that such information and opinion is truthful or made in good faith.

I give permission for a pre-employment drug/alcohol screening exam and, if the company makes a conditional job offer, I give permission for a complete employment physical examination. I also consent to the appropriate release of any and all medical information, as may be deemed necessary.

I understand that, if hired, I may not hold other employment, nor engage in other activities, that create a conflict of interest with my position with the company.

If I become employed, in consideration of my employment, I agree to comply with the fules, regulations, policies and procedures of the company.

If I become employed, in consideration of my employment, I agree that my employment will be at-will, and may be terminated with or without cause, and with or without notice, at any time at the option of myself or the company. Only Board of Directors of Talley, Inc. have the authority to enter into an employment agreement for a specified period of time or for termination only for cause, and any such agreement must be in writing. I understand and acknowledge that this constitutes the entire agreement between me and the company regarding the term of my employment an supersedes any other oral or written agreement.

If offered employment, I understand that a condition of employment is to agree to the Company's problem resolution procedure which includes an agreement to arbitrate as a final and binding step, and I agree the process of my becoming employed will not be complete until I have signed all employment documents.

By checking this box, I agree to the authorization above and have filled out the application to the best of my knowledge. I understand that an electronic signature is as legally binding as a handwritten signature.

Electronic Signature: Date:

VOLUNTARY SELF-IDENTIFICATION INFORMATION

Name: Date:

Position Applying For: Referred By:

APPLICANTS IDENTIFYING THEIR GENDER AND RACE/ETHNICITY

GENDER CLASSIFICATION

Male Female

RACE/ETHNICITY CLASSIFICATION (AS DEFINED BY EEOC)

Asian - (A person having origins in any of the original people of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

Black or African American - (A person having origins in any of the Black racial groups of Africa.)

Hispanic or Latino/White - (A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and of the white race.)

Hispanic / Non-White - (A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and of any race other than white.)

American Indian or Alaskan Native - (A person having origins in any of the original peoples of North America and South America, including Central America, and who maintains tribal affiliation of community attachment.)

White - (A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.)

I choose not to self-identify

Electronic Signature*: Date:

*I understand that an electronic signature is as legally binding as a handwritten signature.