MAXALEA INC. 900 Oak Hill Road Baltimore MD 21239

APPLICATION FOR EMPLOYMENT

An Equal Employment Opportunity Employer Drug Free Workplace

PLEASE PRINT OR TYPE

PERSONAL	NAME: LAST FIRST MIDDLE INITIAL							SOCIAL SECURITY NUMBER
	HAVE YOU EVER USED ANOTHER NAME? Is any additional information relative to change of name, use of an assumed name, or nickname necessary to enable a check on your work and education record? If yes, please explain.							Are you under 18 years OF AGE? r YES r NO
	CURRENT MAILING ADDRESS (Street Number and Name)							HOME TELEPHONE NUMBER
	CITY COUNTY STATE ZIP CODE							PAGER NUMBER
	COUNTRY PROVINCE YEARS/MONTHS AT CURRENT RESIDENCE							CELL/ALTERNATE PHONE #
	PERMANENT FORWARDING ADDRESS (if different from above)							EMAIL ADDRESS
	IF AT CURRENT ADDRESS LESS THAN FIVE YEARS, PLEASE INCLUDE PREVIOUS TEMPORARY AND PERMANENT ADDRESS COVERING THE LAST FIVE YEARS.
	STREET ADDRESS:		CITY:			STATE:	COUNTY:			DATES FROM-TO
	Have you ever applied to work at Maxalea before? r yes r no If yes, when? ______________			Have you ever been employed by Maxalea? r yes r no If yes, when? _______________ former employee #:_________
	HOW WERE YOU REFERRED TO MAXALEA? r Self r Newspaper Advertisement r Agency r Maxalea Website r Internet r Career Fair r Employee Referral ____________________________________ r Other: _______________________________________ (Name of referring person)
	NAMES OF FAMILY MEMBERS EMPLOYED AT MAXALEA				RELATIONSHIP (i.e. spouse, parent, sibling, uncle, etc.)
	TYPE OF POSITION FOR WHICH YOU ARE APPLYING:				SALARY EXPECTED $				DATE AVAILABLE
	TYPE OF EMPLOYMENT YOU ARE SEEKING:
	r Full-time r Part-time	r Regular r Temporary r Summer r College Intern/Co-op r High School Work Experience
	EMPLOYMENT ELIGIBILITY: All employees upon being hired, must complete an Employment Eligibility Verification (Form I-9) as required by Title 8, U.S. Code Section 1324A. Employees will be required to present appropriate documents to Maxalea for verification of legal right to work.
	I attest, under penalty of perjury, that I am (check one of the following):					_____ A citizen of the United Sates
						_____ I have a registration card or US work permit.
	Complete ONLY if applying for a job requiring a drivers license.
	Date of Birth _____/_____/_____
	Driver’s License Number: ___________________________________________					Expiration Date: _____/_____/_____

EDUCATION / TRAINING / SKILLS	List Below your Educational Background, Including High School, All Colleges, Trade and Military Service Schools.
	Indicate last level of education completed:	High School r 9 r 10 r 11 r 12 r GED			Trade School r 1 r 2 r 3 r 4	College or University r 1 r 2 r 3 r 4			Post Graduate r 1 r 2 r 3 r 4
	SCHOOL NAME		ADDRESS, CITY, COUNTY, STATE, ZIP CODE			GRADUATE? Y/N		DEGREE EARNED & MAJOR		GPA
	VOCATIONAL AND/OR PROFESSIONAL INFORMATION (I.E. PROFESSIONAL CERTIFICATION, HONORS, AWARDS, LICENSES, AFFILIATIONS, RESEARCH PROJECTS, THESIS SUBJECT, PUBLICATIONS, PATENTS, SEMINARS, VOLUNTEER WORK). NOTE: DO NOT LIST COURSES TAKEN TOWARDS A DEGREE OR DIPLOMA
	INDUSTRY RELATED SKILLS LIST SKILLS IN THE CATEGORY BELOW, LEVEL OF SKILL AND YOUR MONTHS/YEARS OF EXPERIENCE.
	EQUIPMENT			LEVEL: GOOD, FAIR, POOR			MONTHS / YEARS OF USE
	TECHNICIAN SKILLS
	Can you troubleshoot ? r yes r no If yes, where did you learned how to do this? __________________________________________ When was the last time you did this? ________________________ How much experience do you have doing this? ______ yrs ______ mo. List the types of products you have experience troubleshooting: __________________________________________________________________ _____________________________________________________________________________________________________________________ List the types of equipment you have utilized. Include brand and model: ___________________________________________________________ _____________________________________________________________________________________________________________________
	ADMINISTRATIVE AND COMPUTER SKILLS
	List all administrative skills such as typing speed, data entry strokes, 10-key: _____________________________________________________ ___________________________________________________________________________________________________________________ List all computer languages and proficiency (advanced, intermediate, beginner): ____________________________________________________ ____________________________________________________________________________________________________________________ List all computer software applications and proficiency (advanced, intermediate, beginner): ___________________________________________ ____________________________________________________________________________________________________________________
	OTHER SKILLS
	Describe any other skills you have which you feel may be relevant to the position for which you are applying: ____________________________ ___________________________________________________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

EMPLOYMENT HISTORY	Please list your job history, including volunteer or unpaid experience, starting with your current or more recent position. Include any periods in which you were not employed and explain what you were doing during that time. PLEASE COMPLETE ALL APPROPRIATE ITEMS, EVEN IF YOU HAVE ALREADY PROVIDED A RESUME.
	CURRENT EMPLOYER NAME (Most recent or present employer)		TELEPHONE NUMBER ( )	EMPLOYMENT DATES (MONTH/YEAR) From to
	TYPE OF BUSINESS		FULL OR PART TIME?	IF PART TIME, APPROX. HRS/WEEK WORKED?
	ADDRESS (Street, City, County, State, Zip Code			STARTING BASE SALARY $ per
	YOUR JOB TITLE	CURRENT SUPERVISOR NAME | TITLE		CURRENT/FINAL BASE SALARY $ per
	REASON FOR LEAVING			OTHER COMPENSATION
	May we contact your present employer? r Yes r No If no, may we contact upon your acceptance of our employment offer? r Yes r No			DATE OF LAST INCREASE
	YOUR DUTIES AND RESPONSIBILITIES:
	EMPLOYER NAME		TELEPHONE NUMBER ( )	EMPLOYMENT DATES (MONTH/YEAR) From to
	TYPE OF BUSINESS		FULL OR PART TIME?	IF PART TIME, APPROX. HRS/WEEK WORKED?
	ADDRESS (Street, City, County, State, Zip Code			STARTING BASE SALARY $ per
	YOUR JOB TITLE	SUPERVISOR NAME | TITLE		FINAL BASE SALARY $ per
	REASON YOU LEFT			OTHER COMPENSATION
	YOUR DUTIES AND RESPONSIBILITIES:
	EMPLOYER NAME		TELEPHONE NUMBER ( )	EMPLOYMENT DATES (MONTH/YEAR) From to
	TYPE OF BUSINESS		FULL OR PART TIME?	IF PART TIME, APPROX. HRS/WEEK WORKED?
	ADDRESS (Street, City, County, State, Zip Code			STARTING BASE SALARY $ per
	YOUR JOB TITLE	SUPERVISOR NAME | TITLE		FINAL BASE SALARY $ per
	REASON YOU LEFT			OTHER COMPENSATION
	YOUR DUTIES AND RESPONSIBILITIES:
	EMPLOYER NAME		TELEPHONE NUMBER ( )	EMPLOYMENT DATES (MONTH/YEAR) From to
	TYPE OF BUSINESS		FULL OR PART TIME?	IF PART TIME, APPROX. HRS/WEEK WORKED?
	ADDRESS (Street, City, County, State, Zip Code)			STARTING BASE SALARY $ per
	YOUR JOB TITLE	SUPERVISOR NAME | TITLE		FINAL BASE SALARY $ per
	REASON YOU LEFT			OTHER COMPENSATION
	YOUR DUTIES AND RESPONSIBILITIES:

REFERENCES	Please list three persons best qualified to comment on your related work experience and/or educational background. Include supervisors not listed above. Do not include relatives.
	Name	1.	2.	3.
	Title
	Company
	Address
	Business Telephone	( )	( )	( )
SECURITY	Have you ever been convicted of a felony? r Yes r No If yes, give dates, places, charges and disposition: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Have you been convicted of a misdemeanor or received deferred adjudication within the past 5 years? r Yes r No If yes, give dates, places, charges and disposition: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ A “yes” answer will not necessarily disqualify your application.
	Please initial each blank.
	____________	· I certify that all information furnished on this form is true, complete and correct to the best of my knowledge.
	____________	· I authorize past and present employers, educational institutions and references to verify information on the application and release them to provide additional information relating to my past employment education and performance as requested by Maxalea or its agents.
	____________	· I authorize Maxalea or its agents to verify any such information and understand that falsification or omission of information on the application is grounds for termination of further consideration for employment and/or termination of employment.
	____________	· I understand that Maxalea reserves the right to request a physical examination and drug testing.
	____________	· I understand that overtime may be required and is a condition of employment.
	____________	· In consideration of my employment, I agree to conform to the policies and procedures of the company. I understand that in accepting this application, the company is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. Furthermore, if employed, I understand that I am employed at will and that my employment and compensation can be terminated with or without cause, and with or without notice at any time.
	____________	· I also understand that any offer of employment is conditioned on the completion of pre-employment tests and documentation. I will, upon request, sign all necessary consent forms.
		_______________________________________________________ Signature		__________________ Date