About Omni Systems. There's more to Omni than just low prices.

1. * Full Name:
2. * Position Applying For:
3. Salary Expectations:
4. Referral Source:
5. Full-Time Part-Time Temp
6. 1st Shift 2nd Shift 3rd Shift
7. Driver's License No.:
8. # Home Phone:
9. Alternative Phone:
10. Current Address:
11. Current Address 2:
12. City:
13. State: Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
14. Zip:
15. * Email:
16. Have you applied at Omni Systems previously?
    Yes
    No
17. If so, when? (month/year)
18. Have you ever been employed with Omni Systems previously?
    Yes
    No
19. If so, when? (month/year)

20. In accordance with the Immigration Reform and Control Act of 1986, all associates hired after November 6, 1986, must prove employment eligibility. If employed by Omni Systems, federally required documentation must be provided. Are you able to provide documentation of your eligibility to work in the United States?

    Yes
    No

1. Insert text of your resume, if available:

High School

1. Name:
2. Number of Years Completed:
3. Did you graduate?
   Yes
   No

College/University

1. Name:
2. Major:
3. Number of Years Completed:
4. Did you graduate?
   Yes
   No

College/University

1. Name:
2. Major:
3. Number of Years Completed:
4. Did you graduate?
   Yes
   No

Reference 1

1. Name:
2. Company:
3. Phone:
4. Relationship:

Reference 2

1. Name:
2. Company:
3. Phone:
4. Relationship:

Reference 3

1. Name:
2. Company:
3. Phone:
4. Relationship:

Please provide all information requested, even if attaching a resume. Include all previous employers and military service.

Current or Most Recent Employer

1. Employer:
2. Address:
3. Phone:
4. OK to contact?
   Yes
   No
5. Start date:
6. End date:
7. Position:
8. Supervisor's Name:
9. Supervisor's Phone:
10. Starting Wage/Salary:
11. Ending Wage/Salary:
12. Duties:
13. Reason for Leaving:

Prior Employer

1. Employer:
2. Address:
3. Phone:
4. OK to contact?
   Yes
   No
5. Start date:
6. End date:
7. Position:
8. Supervisor's Name:
9. Supervisor's Phone:
10. Starting Wage/Salary:
11. Ending Wage/Salary:
12. Duties:
13. Reason for Leaving:

Prior Employer

1. Employer:
2. Address:
3. Phone:
4. OK to contact?
   Yes
   No
5. Start date:
6. End date:
7. Position:
8. Supervisor's Name:
9. Supervisor's Phone:
10. Starting Wage/Salary:
11. Ending Wage/Salary:
12. Duties:
13. Reason for Leaving:

Prior Employer

1. Employer:
2. Address:
3. Phone:
4. OK to contact?
   Yes
   No
5. Start date:
6. End date:
7. Position:
8. Supervisor's Name:
9. Supervisor's Phone:
10. Starting Wage/Salary:
11. Ending Wage/Salary:
12. Duties:
13. Reason for Leaving:

1. Please list reasons for any breaks in employment:
2. Have you ever been convicted of a crime, other than a minor traffic offense?
   Yes
   No
3. If yes, please explain:

4. By submitting this application, I certify that the information contained in this application is true and correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to hire, or if hired, dismissal. I authorize investigation of all statements contained in this application concerning my previous employment, education, criminal history or other information, personal or otherwise, and release all parties from liability for any damage that may result from furnishing or obtaining such information.

   If employed, I agree to conform to the policies and regulations of the Company, which I acknowledge may be changed, interpreted, or withdrawn at any time at the Company's discretion and without prior notice. I understand that neither this document nor any offer of employment constitutes an employment contract unless the Company and myself execute a specific and express document to that effect. I further acknowledge that my employment may be terminated, and any offer of employment, if such is made, may be withdrawn, with or without cause and with or without prior notice, at any time, at the option of the Company and myself.

   As a condition of employment, I understand and acknowledge that any offer of employment with Omni Systems is conditional upon my submitting to and successfully passing a hair follicle test and background check. Therefore, I acknowledge and understand that if the drug test results are positive, where a controlled substance is detected, not prescribed by a doctor, the offer of employment will be withdrawn and I will be ineligible for employment at Omni Systems.

   I Agree
   I Do Not Agree