*This form has been revised to comply with the provisions of the Americans with Disabilities Act
and the final regulations and interpretive guidance promulgated by the EEOC on July 26. 1991.
(LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).
GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.
THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTS. [Fill in name of state.)
IT IS UNLAWFUL IN THE STATE OF
AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.
This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination. This Application for Employment Form
is sold for general use throughout the United States. TOPS assumes no responsibility for the inclusion in said form of any questions which, when asked by the Employer of the
Job Applicant, may violate State and/or Federal Law.