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INYO-MONO TITLE COMPANY

Employment Application

An Equal Opportunity Employer

Please Print

Name: Last_____________________First___________________Middle___________________

Business Telephone (____)_________________Home Telephone (___)____________________

Social Security No.____________-_______________-__________________________________

Present Address: No.______Street______________City___________State________Zip_______

Permanent Address if different from present address

No.______Street______________City___________State________Zip_______

Employment Desired

Position Applying for_____________________________________________________________

Are you applying for?

Regular full time work?…………………………………………………Yes______No________

Regular part time work?…………………………………………………Yes______No________

Temporary part time work……………………………………………… Yes______No________

Temporary work, e.g., summer or holiday work?……………………… Yes______No________

What days and hours are you available for work________________________________________

If applying for temporary work, during what period of time will you be available?

From__________________________________________________________________________

Are you available for work on the weekends……………………………. Yes______No________

Would you be available to work overtime if necessary?…………………. Yes______No________

If hired, on what date can you start work?_________________________ Yes______No________

Salary desired?___________________________________________________________________

Employment Application Page 2

Personal Information

Have you ever applied to or worked for Inyo-Mono Title before?_______Yes________No_________

If yes, when?_______________________________________________________________________

Do you have any friends or family working for Inyo-Mono Title? ?______Yes________No_________

If yes, state name(s) and relationship_____________________________________________________

Why are you applying for work at Inyo-Mono Title? _________________________________________

If hired, would you have a reliable means of transportation to and from work? Yes________No_______

Are you at least 18 years old? _______________________________________ Yes________No______

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?
_____________________________________________________Yes________No______

Are you able to perform the essential functions of your job for which you are applying, either with or without
reasonable accommodation.__________________________________ Yes________No______

If no, describe the functions that cannot be performed_________________________________________

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible
applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill
and agility tests.

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for marijuana-related
offenses that are more than two years old need not be listed. Yes________No______

If yes, state the nature of the crime(s), when and where convicted and disposition of the case. _________

(Note): No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of
the offenses, the date of the offenses, the surrounding circumstances and the relevance of the offenses to the position
(s) applied for may, however, be considered.

Are you currently employed_________________________________________ Yes________No______

If so, may we contact your current employer____________________________ Yes________No______

Application Page 3

Education, Training and Experience

School

High School: Name and Address ____________________________ of yrs_____Graduate_____ Degree_________

College: Name and Address ____________________________# of yrs_____ Graduate_____ Degree_________

Vocational: Name and Address ____________________________# of yrs_____Graduate_____ Degree_________

Business

Health: Name and Address ____________________________ # of yrs_____Graduate_____ Degree_________

Care

Many of our customers (clients) do not speak English. Do you speak , write, or understand any foreign language(s).
_____________________________________________________________________

If yes , which laguages?__________________________________________________________________

Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work
at Inyo-Mono Title. If so, please explain._____________________________

Answer the following questions if you are applying for a professional position.

Are you licensed/certified for the job applied for _________________________ Yes________No______

Name the license/ certification ____________________________________________________________

Issuing State___________________________________________________________________________

License/Certificate number________________________________________________________________

Has your license /Certificate ever been revoked or suspended?______________ Yes________No______

If yes, state reason(s), date of revocation or suspension and date of reinstatement
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_____________________________________________________

Employment Application Page 4

Employment History

List below all present and past employment starting with your most recent employer (last 10 years). Account for all
periods of unemployment. You must complete this section even if attaching a resume.

Name of Employer_____________________________________________________________________

Address______________________________________________________________________________

No. Street City State Zip

Type of business_______________________________________________________________________

Telephone Number (______)__________________________Supervisors Name_____________________

Your position and duties__________________________________________________________________

Date of Employment: From___________________________ To _________________________________

Weekly Pay: Starting _____________________ Ending_________________________________________

Reason For
Leaving____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_______________________________________________________________________

Name of Employer_____________________________________________________________________

Address______________________________________________________________________________

No. Street City State Zip

Type of business_______________________________________________________________________

Telephone Number (______)__________________________Supervisors Name_____________________

Your position and duties__________________________________________________________________

Date of Employment: From___________________________ To _________________________________

Weekly Pay: Starting _____________________ Ending_________________________________________

Employment Application Page 5

Employment History

List below all present and past employment starting with your most recent employer (last 10 years). Account for all
periods of unemployment. You must complete this section even if attaching a resume.

Name of Employer_____________________________________________________________________

Address______________________________________________________________________________

No. Street City State Zip

Type of business_______________________________________________________________________

Telephone Number (______)__________________________Supervisors Name_____________________

Your position and duties__________________________________________________________________

Date of Employment: From___________________________ To _________________________________

Weekly Pay: Starting _____________________ Ending_________________________________________

Name of Employer_____________________________________________________________________

Address______________________________________________________________________________

No. Street City State Zip

Type of business_______________________________________________________________________

Telephone Number (______)__________________________Supervisors Name_____________________

Your position and duties__________________________________________________________________

Date of Employment: From___________________________ To _________________________________

Weekly Pay: Starting _____________________ Ending_________________________________________

Employment Application Page 6

Military Service

Have you obtained any special skills or abilities as the result of service in the Military?Yes___No___

If so please describe.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________

References:

List below three persons not related to you who have knowledge of your work performance within the last three years.

Name _______________________________________________________________________________

Address______________________________________________________________________________

No. Street City State Zip

Occupation____________________________________________________________________________

Telephone # ( )_______________________Number of years acquainted________________________

Name _______________________________________________________________________________

Address______________________________________________________________________________

No. Street City State Zip

Occupation____________________________________________________________________________

Telephone # ( )_______________________Number of years acquainted________________________

Name _______________________________________________________________________________

Address______________________________________________________________________________

No. Street City State Zip

Occupation____________________________________________________________________________

Telephone # ( )_______________________Number of years acquainted________________________

Employment Application Page 7

Please Read Carefully, Initial Each Paragraph and Sign Below

______ I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for
employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I,
the undersigned applicant, have personally completed this application. I understand that any omission or misstatement
of material fact on this application or on any document used to secure employment shall be grounds for rejection of this
application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

______ I hereby authorize the company to thoroughly investigate my references, work record, education and other
matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the
company any and all letters, reports, and other information related to my work records, without giving me prior notice of
such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations,
partnerships and associations from any and all claims, demands or liabilities arising our of or in any way related to such
investigation or disclosure.

______I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this
application. I further agree, in thew event that I am hired by the company, that all disputes that cannot be resolved by
informal internal resolution which might arise out of my employment with the company, whether during or after that
employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of
the American Arbitration. This application contains the entire agreements as to dispute resolution, either oral or written

______I understand that nothing contained in the application, or conveyed during any interview which may be granted
or during my employment if hired, is intended to create an employment contract between me and the company. In
addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may
be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no
promises or representations contrary to the foregoing are binding on the company unless made in writing and signed
by me and the company representative.

Date:______________________Applcant's signature_______________________________________