Position Applied For:
Applicant DataPlease Answer All Questions. Do Not Leave Any Blanks.
Last Name:
First Name:
Middle Name:
Address:
Apt. No.
City:
State
Zip Code
Phone Number:
Alt. Phone
E-Mail
When will you be available to start work?
Salary Requested $
Are you at least 18 years old?
YesNo
If NO, state your age for child labor law purposes only
Are there any days, shifts or hours you will not work?
If YES, please explain:
Are you available for out of town work?
Available for overnight travel, if required
Will you work overtime, if required?
Work adjusted hours, if required?
Have you taken any illegal drugs within the last 30 days?
if YES,Please explain:
Were you referred to us by?
Have you ever work for the Company
EMPLOYMENT HISTORY
Employer Name & Location
Job Title & Duties
Start & End Dates Reason for Leaving
Rate of Pay
EDUCATION
Learning Institution
Name & Location
Years Attended
Degree / Certificate
GENERAL INFORMATIONANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS
Have you had employment gaps longer than 3 months?
If yes, please explain
Have you ever been discharged or forced to resign?
Have you received any disciplinary counseling in your last twelve months of employment?
Were you given a performance review during your last 12 months of active employment?
If yes, what was your score?
Have you signed any employment agreements and/or non-compete/non-solicit agreements with another employer that might restrict you from working for this company?
DRIVING RECORDANSWER ONLY IF DRIVING IS A REQUIREMENT FOR THE JOB FOR WHICH YOU ARE APPLYING
Do you have a valid driver’s license?
License No.
Have you had any tickets?
Has your license ever been suspended or revoked?
Do you have any DUI or DWI convictions?
If yes, please state when you were convicted and explain
ACKNOWLEDGEMENT AND AGREEMENT
I certify that the answers given herein are true and complete to the best of my knowledge. I understand that if employed, any misrepresentations, omissions of facts or incomplete answers in any document will be cause for my immediate dismissal at any time without prior notice. I understand that, if employed my employment is not for a specific term and may be terminated by me or Company with or without notice or cause at any time. I further understand that no oral promise, employer policy, custom, business practice or other procedure (including the Employee Handbook or any other personnel manual) constitutes an employment contract or modification of the at-will employment relationship between me and the Employer. I authorize the Company to contact my prior employers, and other sources of information regarding my background, and I indemnify the Company and sources of information contacted and agree to hold all harmless from any claims arising from information obtained through this authorization and direction. I understand that this application will be considered active for 30-calendar days from this date. If I have not heard from the company at the conclusion of the 30-calendar day period, it is my responsibility to complete a new application if I wish to be considered for employment.
SIGNATURE:
Date:
The Company and all affiliates is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of any category protected by or prohibited by federal, state, or local law. In accordance with the Americans with Disabilities Act, it is our policy to provide reasonable accommodation upon request during the application process to eligible applicants in order that they may be given a full and fair opportunity.
