EMPLOYMENT APPLICATION

Please complete the entire application.

1. Employer Information:
Employer: 7TH & Madison Extensions of Empowerment
Address: 78 John Miller Way, Suite 326
City/State/ZIP: Kearny, New Jersey 07032
Telephone: (800) 936-3256

It is the policy of 7TH & Madison Extensions of Empowerment to provide equal employment
opportunities to all applicants and employees without regard to any legally protected status such as
race, color, religion, gender, national origin, age, disability or veteran status.

CERTIFICATION

I certify that the information provided on this application is truthful and accurate. I understand that
providing false or misleading information will be the basis for rejection of my application, or if
employment commences, immediate termination.

I authorize 7TH & Madison Extensions of Empowerment to contact former employers and
educational organizations regarding my employment and education. I authorize my former
employers and educational organizations to fully and freely communicate information regarding my
previous employment, attendance, and grades. I authorize those persons designated as references
to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written
contract of employment signed on behalf of the organization by its Director, the employment
relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and
either I or my employer will be able to terminate the employment relationship at any time and
without cause. With appropriate notice, I will have the full and complete discretion to end the
employment relationship when I choose and for reasons of my choice. Similarly, my employer will
have the right. Moreover, no agent, representative, or employee of 7TH & Madison Extensions of
Empowerment, except in a specific written contract of employment signed on behalf of the
organization by its Director, has the power to alter or vary the voluntary nature of the employment
relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND
AND AGREE TO ITS TERMS.

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APPLICANT SIGNATURE

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DATE