BG #

Code:

2301 S. College Road Lafayette, La 70508

INSTRUCTIONS: PLEASE READ BEFORE YOU BEGIN

Complete ALL sections of this application. The application must be completed, submitted by the applicant, and reviewed by Human Resources prior to being accepted. Answers should be PRINTED in ink so they are clear and readable. While we are happy to accept a resume, it CAN NOT be substituted for a completed application. Applications will be kept on file for six (6) months.

AN EQUAL OPPORTUNITY EMPLOYER

Qualified applicants receive consideration for employment without regard to or discrimination as to race, color, national origin, gender, marital status, creed, religion, age, mental or physical handicap, or veterans status.

IF A SECTION DOES NOT APPLY TO YOU, WRITE N/A IN THAT SECTION

Employment Application
Date of Application . Home or Message Phone Number....................... Alternate Phone Number ...................... Social Security Number ...... Position Applied for ....................................... Salary Expected How did you find out about the position? .............................. Date of availability .

PERSONAL INFORMATION
NAME: Last: Present Address: Permanent Address: In case of emergency, Please Notify: Are you prevented from lawfully becoming employed in this country Yes because of a visa or immigration issue? If hired, can you provide Taylors with proof of citizenship, a visa, and/or an alien registration number? Yes No First: Apt. #: Apt. #: Relationship: No City: City: Middle: State: State: Phone Number: Are you 18 years or older? Yes No Zip: Zip:

Due to the nature of the business, do you have your own transportation? Are you currently employed? Who referred you to us? Have you ever worked for this company before? NOTICE: Yes No Yes No

Yes

No

Drivers License #: Yes No

State:

May we contact them?

If yes, When:

Where:

The secretary of HEALTH & HUMAN SERVICES has determined that certain diseases, including Hepatitis A, Salmonella, Shigella,

Staphylococcus, Streptococcus, Giafria, E. coli, and Campylobacter may prevent you from serving food or handling food equipment in a sanitary or healthy fashion. An essential function of this job involves handling and serving food, food service equipment and utensils in a sanitary and healthy fashion. Is there any reason why you cannot perform these essential functions of this job? Yes No

CRIMINAL HISTORY
Criminal history does NOT disqualify you for employment. Have you ever had a criminal record? Yes No

If yes, with regards to each offense, please provide the type of offense, the date and location of the arrest or charge, and its disposition (e.g. dismissal, not guilty, guilty; and, if guilty, also provide the sentence imposed and the status of any probation, parole, or supervisory term). Offense . Date .. Location . Disposition ............................................... Offense . Date .. Location . Disposition .... Offense . Date .. Location . Disposition ............................................... If you have ever plead guilty, or been found guilty after a trial of a criminal offense, are you currently on probation, parole, or other supervisory program? Yes No If yes, Name Phone number

EDUCATION
Grammar School: High: College: Trade/Business/Grad./Other: Special training, skills, certifications, experience, etc.: _ Location: Location: Location: Years Attended: Years Attended: Years Attended: Graduated: Yes Graduated: Yes Graduate: Yes _ No No Studies: Studies: No Studies: No

Years Attended:

Graduated: Yes

MILITARY SERVICE RECORD

Branch of Service: Present Military Service: Highest Rank: Active Reserves Date Entered: Inactive Reserves Yes No Discharge Date:

Do you have service related skills and experience applicable to civilian employment? If so, please describe:

REFRENCES
List the name, address and telephone number of three people who are not related to you and are not previous employers as references. Name Address Telephone Years Known

EMPLOYMENT HISTORY
List below your employment history for the past ten (10) years STARTING with your present or last job. Explain all gaps in employment. Attach additional sheets if necessary. DO NOT SUBSTIUTUTE YOUR RESUME FOR THIS INFORMATION. Company name, address, and telephone: Name: Address: City: Telephone: Company name, address, and telephone: Name: Address: City: Telephone: Company name, address, and telephone: Name: Address: City: Telephone: Company name, address, and telephone: Name: Address: City: Telephone: Company name, address, and telephone: Name: Address: City: Telephone: State: To: Supv. Name: End: Date: (mo & yr) From: Job title & Supv. Job title: Job duties: Pay rate: Start: Reason for leaving: Resignation Layoff Involuntary Termination Explanation: State: To: Supv. Name: End: Date: (mo & yr) From: Job title & Supv. Job title: Job duties: Pay rate: Start: Reason for leaving: Resignation Layoff Involuntary Termination Explanation: State: To: Supv. Name: End: Date: (mo & yr) From: Job title & Supv. Job title: Job duties: Pay rate: Start: Reason for leaving: Resignation Layoff Involuntary Termination Explanation: State: To: Supv. Name: End: Date: (mo & yr) From: Job title & Supv. Job title: Job duties: Pay rate: Start: Reason for leaving: Resignation Layoff Involuntary Termination Explanation: State: To: Supv. Name: End: Date: (mo & yr) From: Job title & Supv. Job title: Job duties: Pay rate: Start: Reason for leaving: Resignation Layoff Involuntary Termination Explanation:

CERTIFICATION AND AGREEMENT -

READ CAREFULLY BEFORE SIGNING - I UNDERSTAND AND AGREE THAT:

25 U.S.C. 2701 SEC556.3 Notice Regarding False Statements 1) Any misrepresentation or omission of facts in my application or any attachments to my application may result in refusal of employment or if employed, termination of employment 2) It is my understanding that Taylors International Services, Inc. may make a thorough investigation of my work, educational, and personal history and may verify all data given in my application, related papers, or oral interview. I authorize such investigation and the giving and receiving of any information requested by Taylors International Services, Inc., and I release from any liability any person giving or receiving any such information. I understand that falsification of data so given or other derogatory information discovered as a result of this investigation may result in refusal of employment, or if employed, termination from employment. 3) I understand and agree that any person authorized by Taylors International Services, Inc. can at any time request that I submit to a search of my person, purses, packages in my possession, or any locker, desk, or files that may be assigned to me. I understand that my refusal to submit to such a search may result in my termination. I hereby waive all claims for damages resulting from such examination. 4) I understand and agree that I may be required to take a physical examination, blood, urine, or hair test by Taylors International Services, Inc. at any time to determine if I am alcohol or drug free and physically fit for the job I am responsible to perform. Failure to submit to such testing may result in termination. I authorize any physician, including my personal physician, to release any information to Taylors International Services, Inc. which may be necessary to determine my ability to perform my assigned duties. 5} I further understand that Taylors International Services, Inc. can change wages, benefits, and/or working conditions at any time and that I may be required to work overtime, weekends, and/or holidays. 6} I understand that Taylors International Services, Inc. may, from time to time, establish rules, regulations, policies, guidelines, and/or disciplinary procedures, some of which may be reduced to writing. In consideration of my employment, I agree to conform to all applicable rules, regulations, policies, guidelines, and/or disciplinary procedures of Taylors International Services, Inc. and/or any department thereof. I understand that those rules, regulations, policies, guidelines, and/or disciplinary procedures are not intended by Taylors International Services, Inc. to create an obligation of continued employment. 7) I understand that this document is an application for employment and continued employment is not being offered. I hereby understand and agree that my employment, both during and after any introductory or orientation period, is for an indefinite period, and that nothing in this application or any other Taylors International Services, Inc. document shall be deemed to create any contract of continued employment between me and Taylors International Services, Inc. I further understand that my employment can be terminated at will at any time by myself or Taylors International Services, Inc. for any or no cause. I understand that employment beyond any introductory or orientation period or employment for a number of years shall not result in any heightened expectation of continued employment. I understand and agree that any statements to the contrary, whether oral or written, are expressly disavowed and are not to be relied upon by me. I further understand that no representative of Taylors International Services, Inc. has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing except in a written document signed by the general manager. I, THE UNDERSIGNED, have read the Privacy Notice, Notice Regarding False Statements and all other information included in this application for employment and undersigned and agreed with all of their terms. Applicants Signature Date

NOTICE REGARDING CONSUMER REPORTS

A consumer report containing information concerning your employment history, criminal records and motor vehicle records may be obtained in connection with your application for and / or continued employment with the company. A consumer report containing injury and illness records and medical information may be obtained after a tentative offer of employment has been made. Before any adverse action is taken, based in whole or in part on the information contained in the consumer report, you will be provided a copy of the report, the name, address, and telephone number of the reporting agency, a summary of your rights under the Fair Credit Reporting Act, as well as additional information on your rights under the law. CONSENT TO OBTAINING CONSUMER REPORTS READ CAREFULLY BEFORE SIGNING I have read the above Notice to Applicants / Employees Regarding Consumer Reports and hereby authorize the company to obtain consumer reports as described.

PRINT NAME

SOCIAL SECURITY NUMBER

SIGNATURE

DATE

Authorization for Release of Information

PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW
I hereby declare that the answers to the questions on this application are correct and that any misstatement or omission of fact will be sufficient cause for rejection of any application or separation should I become employed by the Company. I authorize the Company and its agents to contact any of my previous employers as well as any reference source in order to verify the facts and information I have furnished regarding my qualifications and character. I hereby authorize any person(s) having knowledge thereof to provide such information to the Company or its agents, and I hereby release from liability and agree to hold harmless any person that furnishes such information in good faith. I authorize the Company and its agents to supply my employment record in whole or part and in confidence to any employer, insurance agency, or other party with a legal and proper interest, and I hereby release the Company and its agents from any liability and agree to hold harmless any employee of the Company or its agents who furnishes such information. I further understand that my employment is for no fixed time and just as I am free to resign at any time, the Company reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no employee, officer, or agent of the Company may bind it by oral or printed statements, including handbooks, benefits books, or bulletins, contrary to the above. I also declare that I am able to perform all essential functions of the position applied for in this application with or without a reasonable accommodation. I agree that if I am offered a position with Company, such offer will be contingent on the results of a medical examination, including urinalysis and agility testing. I understand that if employed, I will be subject to testing for the presence of illegal drugs on a random, post-accident, and reasonable cause basis. I further understand that the Company may require me to undergo additional physical examinations if such examinations are job-related and justified by business necessity. I hereby release the Company or its agents from any liability resulting from any of the tests listed above. Under the provisions of the Fair Credit Reporting Act, 15 U.S.G. Sec. 1681, et seq., notice is hereby given that a consumer report or investigative consumer report may be obtained which may include but not limited to: criminal history, civil history, motor vehicle report, work history, workers compensation history, educational history, information to your credit worthiness, character, general reputation, personal characteristics, and mode of living, which will be used for employment purposes. An investigation into your workers conducted. You are further advised under said Act that any person who produces or causes to be prepared any investigative consumer report on any consumer, upon written request made by the consumer within a reasonable period of time after the receipt by him/her of the disclosure required by subsection 1681 (d), shall make a complete and accurate disclosure of the nature and scope of the investigation requested. This disclosure shall be made in writing, mailed or otherwise delivered, to the consumer not later than five days after the date on which the request for such disclosure was received from the consumer or such report was first requested, whichever is the later. You are further advised that if you are denied employment, either wholly or in part, because of information contained in a consumer report as that term is defined in the Fair Credit Reporting Act that a disclosure will be made to you of the name and address of the consumer-reporting agency making such report. I have carefully read the information on this form, realize I have had the opportunity to ask questions about it, and understand what it means. compensation or industrial accident background may also be

SIGNATURE OF APPLICANT

SOCIAL SECURITY NUMBER

PRINTED NAME OF APPLICANT a)

DRIVERS LICENSE NUMBER

STATE LICENSE ISSUED b) ADDRESS OF APPLICANT TODAYS DATE DATE OF BIRTH Conducted by Assured Security and Compliance, LLC In the interest of; PLACE OF BIRTH (CITY) TAYLORS INTERNATIONAL SERVICES INC.

CONFIDENTIAL AFFIRMATIVE ACTION SURVEY

TO ALL APPLICANTS: Qualified applicants are considered for employment, and employees are treated during employment, without regard to race, color, religion, sex, age, national origin, citizenship, veteran status, disability, or other factors protected by federal, state, or local law. In order to enable us to meet government reporting requirements and maintain an Affirmative Action Program, we request that you complete this personal data form. Provision of this information is VOLUNTARY and refusal to provide it will not subject you to any adverse treatment. This information will be kept in a CONFIDENTIAL file, separate from the application for employment and will not be considered for employment purposes. It will only be used in accordance with the provision of applicable laws and regulations. Your cooperation is appreciated. PLEASE PRINT Name (Last, First, Middle): Address (Street, City, State, Zip): Phone Number: Are you a Military Veteran? Yes or No Position Applied for: Social Security Number: Sex: Male Female Vietnam Veteran? Yes or No

What is your race/ethnicity? You may mark only one box. Hispanic or Latino White Black or AfricanAmerican Native Hawaiian or other Pacific Islander Asian
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. (not Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. (not Hispanic or Latino) A person having origins in any of the black racial groups of Africa. (not Hispanic or Latino) A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

(not Hispanic or Latino) A person having origins in any of the original peoples 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. (not Hispanic or Latino) A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. (not Hispanic or Latino) A person who identifies with more than one of the above five races.

American Indian/ Alaskan Native Two or more Races

Signature: Date