Application for Employment

Imprimis, Inc. is an Equal Opportunity Employer and affords equal opportunity employment for all positions without regard to race,color, religion, gender, national origin, age, disability, veteran status, or any other status protected under local, state, or federal laws.

Position Applying for Todays Date

General Information:

Last Name First Name Middle Initial
Street Address
City, State, Zip
Home Phone Message Phone Cell Phone

How did you hear about Imprimis, Inc.?
Are you legally eligible to work in the U.S.? Are you over 18 years of age?
Do you currently have or have you had a security clearance?
If yes, provide the type/level/dates held.

During the last seven years have you been convicted of a felony? A conviction will not necessarily disqualify you from employment. If yes, provide the following information: 1) charges; 2) conviction date(s); 3) place;4) court; 5) sentence or other action.

Education:

Name/Location Course of Study Date Received

High School

Vocational

College

Graduate

Please list any academic honors, scholarships, offices held, etc. Donot list any which reflect your race, color, national origin, disability,or veteran status.

Describe any specialized training, apprenticeships, licenses,certifications, or skills.

Have you received any specialized job-related training in the U.S. military or elsewhere? Please give dates and explanation.

References

Please list two persons who are not related to you or previous supervisors who can provide information about you.

Name City
State Phone Number Relationship
Occupation Years Known

Employment History

(Last seven years) - Begin with your current or most recent employer. Do not exclude any employment, including temporary assignments.

Company From To
Salary Start Salary End
Address Phone
Describe your duties

Reason for leaving

Military Experience

Branch From To Rank at Discharge
Type of Discharge If other than Honorable, please explain

Please provide any other information that you feel wil help us in considering your application for employment:

Application Acknowledgement and Authorization

PLEASE READ CAREFULLY BEFORE SIGNING.

I hereby certify that all of the information provided by me in this application (or any other accompanyingdocuments) is correct, accurate, and complete to the best of my knowledge. I understand that thefalsification or misrepresentation or omission of any facts in said documents will be cause of denial ofemployment or termination of employment regardless of the timing or circumstances of discovery.I understand that submission of an application does not guarantee employment. I further understand thatif an offer of employment is extended by Imprimis, Inc. (the Company), such employment is strictly "at will,"for no specified duration, and may be terminated by either the Company or myself at any time, with orwithout cause or notice. I understand that none of the documents, policies, procedures, actions,statements of Company representatives used during the employment process is deemed a contract ofemployment, real or implied.I understand that no representative of the Company, except the President, has the authority to enter intoany agreements guaranteeing any conditions of employment and that any agreement contrary to theforegoing statements must be made in writing and signed by the President of the Company.I understand that the position for which I am being considered for employment may required that I obtain asecurity clearance. I authorize the Company or the federal government to conduct any securityinvestigation necessary to determine if I may be granted a security clearance. I agree to fully cooperatewith any such security investigation. If I am not able to receive a security clearance, I understand that theCompany may refuse to hire me, may rescind a conditional offer of employment, or terminate myemployment. I agree that the Company will not have any liability to me for not hiring me or terminating myemployment based on my inability to obtain a security clearance. I understand and agree that theCompany does not have an obligation to place me in an alternate position that does not require a securityclearance.I hereby authorize all schools, former employers, references, courts, and any others who have informationabout me to provide such information to the Company and/or any of its representatives, agents, or vendorsand I release all parties involved from any and all liability for any and all damage that may result fromproviding such information.By signing below I acknowledge that I have read, understood, and agree to the above statements.

Signature: Date:

Name and telephone number of person completing this form, if other than the applicant.
Name: Telephone Number:

Imprimis, Inc. Voluntary EEO Survey

Applicant's Name Date:

EXPLANATION

Imprimis, Inc., is subject to certain governmental recordkeeping and reporting requirements for theadministration of civil rights laws and regulations. In order to comply with these laws, i2 invites employees tovoluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal toprovide it will not subject you to any adverse treatment. The information obtained will be kept confidentialand may only be used in accordance with the provisions of applicable laws, executive orders, and regulations,including those that require the information to be summarized and reported to the federal government for civilrights enforcement. When reported, data will not identify any specific individual.

Part 1. DECLINATION
I prefer not to provide any of the information contained in this self-identification form.

Part 2. GENDER
Male Female

Part 3. ETHNICITY

Your application will be submitted to our Human Resourses Department:

Thank you.