Job Application Form

Position applied for:
Referral Source:
Name of source (if applicable):
Last Name:
First Name:
Middle Name:
Street Address:
City:
State:
Zip:
Email Address:
How many years have you lived at this address?
Telephone Number:
May we contact you at work?
If yes, when is the best time to call?
Have you previously worked for this company or any company affiliates?
If yes, in what capacity?
Are you related in any way to anyone who is employed or has been employed by this company?
If yes, list person or persons.
Type of employment desired
Date available for work
Will you work overtime if required?
If hired, do you have a reliable means of transportation to get to work?
If hired, can you provide a curret Driver's License?
Driver's License #
If hired, can you provide a curret Auto Insurence Card?
What languages do you speak?
Have you ever been convicted of a felony or a misdemeanor crime?
If yes, give the date, place, nature of conviction, and explanation of circumstances (conviction will not necessarily disqualify you for employment)

Educational Background

Type of School Name and Address Years Attended Graduated Course or Major
Grammar or Grade School
High School
College
Post Graduate
Business or Trade

Personal References (Excluding Former Employers or Relatives)

Name and Occupation Address Phone Number
1)
2)
3)
Are you 18 years of age or older?
Are you legally eligible for employment in the U.S.A.?
Have you ever been bonded?
If yes, for what job(s)?
If required, could you reside on property?
If required, could you supply your own truck and tools (applies to maintenance only)?

Person to be notified in case of an acccident or emergency

Name
Address
Telephone
Relationship

Previous Work History

(list in order, last or present employer first)
Employer
Telephone
Supervisor at this Employer
Supervisor's Contact Phone Number
Date Employed From
Date Employed To
Address
Job Title
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Reason for Leaving
May we contact for reference?
Summarize the nature of the work performed and job responsibilities
Employer
Telephone
Supervisor at this Employer
Supervisor's Contact Phone Number
Date Employed From
Date Employed To
Address
Job Title
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Reason for Leaving
May we contact for reference?
Summarize the nature of the work performed and job responsibilities
Employer
Telephone
Supervisor at this Employer
Supervisor's Contact Phone Number
Date Employed From
Date Employed To
Address
Job Title
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Reason for Leaving
May we contact for reference?
Summarize the nature of the work performed and job responsibilities
Employer
Telephone
Supervisor at this Employer
Supervisor's Contact Phone Number
Date Employed From
Date Employed To
Address
Job Title
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Reason for Leaving
May we contact for reference?
Summarize the nature of the work performed and job responsibilities

Skills and Qualifications

Summarize any special training, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job-related functions, for the positions which you are applying.


PLEASE READ CAREFULLY APPLICANT'S CERTIFICATION AND AGREEMENT

I understand that any offer of employment made to me is conditioned upon the results of a medical examination, criminal background screening, and/or drug screening, which may be required by the Company.

I understand that I may be required to submit to drug and/or alcohol testing from time to time, and agree and consent to such testing as may be required by the Company as a term and condition of hiring or employment. I understand that the Company may conduct an investigative consumer report concerning my character, general reputation, personal characteristics and mode of living, and that, upon written request to the Company, I can obtain information on the nature and scope of the investigation, if any.

I further authorize the release of the results of these tests and screenings to the Company. I authorize the Company to make any investigation it deems appropriate concerning me, and authorize any public agency, person, company, organization, doctor or medical facility to release such information, including information concerning any prior criminal convictions.

I understand that if employed, my employment will be for an indefinite period of time, and that I may terminate my employment at any time for any reason, and that the Company may do likewise. I further understand that no representative of the Company has authority to enter into any agreement to the contrary, unless such agreement is in writing and signed by the president of the Company.

This application will be considered current for 30 days. After the 30 days, if you still want to be considered, it will be necessary for you to fill out a new application. All questions must be answered for this application to be considered.

I understand that if employed, any misrepresentation or omission of fact on this application shall be considered grounds for my dismissal.

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