Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Social Security Number
*
Phone
*
(###)
###
####
Email
*
Present Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Permanent Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Did you complete Grammar School?
*
Yes
No
Name & Location of Grammar School
*
Special Studies and Degrees/Certificates Received?
*
Did you graduate High School?
*
Yes
No
Name & Location of High School
*
Special Studies and Degrees/Certificates Received?
*
Did you graduate College?
*
Yes
No
Name & Location of College
*
Special Studies and Degrees/Certificates Received?
*
Did you graduate Trade, Business, or Correspondence School?
*
Yes
No
Name & Location of Trade School, Business, or Correspondence School?
*
Special Studies and Degrees/Certificates Received?
*
Do you have any additional subjects of special study or research work?
*
Job Related Skills (Typing, Driver's License, etc.)
*
Activities other than Religious? (Civic, Athletic, etc.)
*
EXCLUDE ORGANIZATIONS, THE NAME OR CHARACTER OF WHICH INDICATES THE RACE, SEX, COLOR OR
NATIONAL ORIGIN OF ITS MEMBERS
Former Employer 1
*
Please include name and address of employer, your dates of employment, position, your salary upon leaving, and reason for leaving.
Former Employer 2
*
Please include name and address of employer, your dates of employment, position, your salary upon leaving, and reason for leaving.
Former Employer 3
*
Please include name and address of employer, your dates of employment, position, your salary upon leaving, and reason for leaving.
Former Employer 4
*
Please include name and address of employer, your dates of employment, position, your salary upon leaving, and reason for leaving.
Personal Reference 1
*
Please list a person not related to you, whom you have know at least one year as a reference. Please include your reference's name, address, phone number, position, and years acquainted.
Personal Reference 2
*
Please list a person not related to you, whom you have know at least one year as a reference. Please include your reference's name, address, phone number, position, and years acquainted.
Personal Reference 3
*
Please list a person not related to you, whom you have know at least one year as a reference. Please include your reference's name, address, phone number, position, and years acquainted.
Authorization & Signature
If you are to be hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.
AUTHORIZATION
I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the Company.
I understand that any employment is conditioned on a background check. I authorize the Company to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character, and general reputation to the Company, without giving me prior notice of such disclosure. In addition, I release the Company, any former employers, and all references listed above from any and all claims, demands, or liabilities arising out of or related to such investigation or disclosure.
I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be “at will” and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing.
If I am offered employment, I agree to submit to a medical examination and drug test before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by the Company and as permitted by law. I consent to such examinations and tests, and I request that the examining doctor disclose to the Company the results of examinations or tests, which results shall remain confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug tests, and if I am hired, a condition of my employment will be that I abide by the Company’s Drug and Alcohol Policy.
I understand that filling out this form does not indicate there is a position open and does not obligate the Company to hire. If hired, I agree to abide by all Company work rules, policies, and procedures. The Company retains the right to revise its policies or procedures, in whole or in part, at any time.
Date Signed
MM
DD
YYYY
