PERSONAL Full Name:
Last
First
Middle
Present Address:
Number & Street
City
State
Zip Code
Home Phone:
Alternate Phone:
How long have you lived here?
Previous Address:
Number & Street
City
State
Zip Code
How long did you live there?
Are you 18 or older?
Yes
No
If not how old?
Have you been convicted of a felony?
Yes
No
(Conviction does not automatically exclude you from employment consideration) If yes, please explain
JOB INTEREST What position you desire?
Hourly rate $ required
What date will you be available for employment?
Are you looking for full time, temporary, part time, or summer?
If part time, what days & hours can you work?
Will you work weekends? Yes
No
Will you work nights? Yes
No
Do you have transportation? Yes
No
If no, please explain.
If employed by us, would you be employed with any other organization, or self-employed? Yes
No
If yes, please explain.
May we contact your present employer for reference?
Yes
No
Phone #
EMPLOYMENT HISTORY
List your employment below, beginning with the present or last place worked.
1. Company Name
From
To
Duties Performed
Reason for leaving
Supervisor
Address
Phone #
2. Company Name
From
To
Duties Performed
Reason for leaving
Supervisor
Address
Phone #
3. Company Name
From
To
Duties Performed
Reason for leaving
Supervisor
Address
Phone #
In connection with my application for employment (including contract for services) with you, I understand the investigative
background inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will
include information as to my character, work habits, performance and experience along with reasons for termination of
past employment from previous employers. Further, I understand that you will be requesting information from previous
employers. Furthermore I understand that you will be requesting information from various federal, state and other
agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil and other
experiences as well as claims involving me in the files of insurance companies. I also understand that as part of the
Company's procedure for processing my employment application, an investigation may be made whereby information is
obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. This inquiry
includes information as to my character, general reputation, personal characteristics and mode of living. I understand that
I have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of
additional information concerning the nature and scope investigation. If hired I understand that I can leave at anytime or
can be terminated at any time. I also understand my continued employment may be subject to the issuance and continued
maintenance of a bond by the bonding agent of the Company. I will abide by all Company policies and procedures and will
comply with all safety requirements and wear or use protective clothing or devices required by federal or state law and the
Company. If requested, I will take a pre-employment physical examination from a physical designated and paid for by the
Company. I agree that if the Company finds I have made any intentional omissions or misrepresentations on this
application, it may eliminate me from further consideration or withdraw any offer of employment or terminate my
employment with any obligation on its part, except for payment to me for services already rendered.
Authorization
Without reservation, I authorize any part or agency contacted by this employer to furnish the above mentioned
information.
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