| Personal Information |
| Name:* |
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| Address:* |
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| City:* |
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| State:* |
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| Zip:* |
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| Phone:* |
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| Email:* |
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| Referred By: |
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| Social Security Number: |
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| Are You At Least 18 Years Old? |
Yes
No |
| If not, please tell us your age for Child Labor Law Purposes |
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| Are there any days, shifts, or hours that you are not able to work? |
Yes
No |
| If yes, explain: |
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| Answering yes to any of the next three questions will not necessarily disqualify you. |
| Have you ever pled guilty, been convicted, entered a plea of no contest, had prosecution deferred or adjudication withheld for any crime? (other than minor traffic violations) |
Yes
No |
| Are there any criminal charges pending against you? |
Yes
No |
| Have you ever been named in a civil action or intentional tort, including but not limited to, assault, battery, false imprisonment, rape, etc.? |
Yes
No |
| If "yes" to any of the above three questions, please give dates and details: |
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| Have you taken any illegal drugs in the last 30 days? |
Yes
No |
Have you ever applied for work or
been employed here before? |
Yes
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| If yes, explain: |
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| Do you have a reliable form of transportation? |
Yes
No |
| Will you work overtime if required? |
Yes
No |
| Can you submit documentation within three days after employment verifying that you are legally eligible to work in the United States? |
Yes
No |
| How did you learn of our company? |
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| Employment Information |
| Position Desired: |
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| Date you can start? |
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| Salary required? |
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| Are you presently employed?* |
Yes
No |
| May we contact your present employer?* |
Yes
No |
| Did you email your resume? |
Yes
No
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| Education History |
| High School: |
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| College: |
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| Trade, Business or Correspondence School: |
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| Current / Most Recent Employer |
| Date From: |
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| Date To: |
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| Company Name: |
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| Address of Employer: |
(Include city, state, zip) |
| Phone w/Area Code: |
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| Salary: |
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| Supervisor: |
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| Position and duties: |
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| Reason for Leaving: |
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| Previous Employer (1) |
| Date From: |
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| Date To: |
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| Company Name: |
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| Address of Employer: |
(Include city, state, zip) |
| Phone w/Area Code: |
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| Salary: |
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| Supervisor: |
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| Position and duties: |
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| Reason for Leaving: |
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| Previous Employer (2) |
| Date From: |
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| Date To: |
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| Company Name: |
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| Address of Employer: |
(Include city, state, zip) |
| Phone w/Area Code: |
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| Salary: |
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| Supervisor: |
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| Position and duties: |
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| Reason for Leaving: |
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| Explain any gaps in your employment history: |
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| List any work-related knowledge, skills, abilities, training, or experience you believe are relevant to the job for which you are applying: |
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| Have you ever been terminated or forced to resign? |
Yes
No |
| If yes, please explain each occasion: |
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| Did you receive any discipline in you last 12 months of employment? |
Yes
No |
| If yes, please explain each occasion: |
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| Were you given a performance evaluation in your last 12 months of employment? |
Yes
No |
| If yes, please state score received and the scale used: |
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| Have you signed any non-compete agreement with any other employer that would restrict you from working with this company? |
Yes
No |
| If yes, please explain: |
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| Driving Record |
| Do you have a valid driver's license? |
Yes
No |
| If yes, what is your license Number: |
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| Have you had any tickets? |
Yes
No |
| If yes, explain: |
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| Has your license ever been suspended or revoked? |
Yes
No |
| If yes, explain: |
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| Do you have any DUI or DWI convictions? |
Yes
No |
| If yes, explain: |
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| Please provide any additional relevant details: |
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| Acknowledgements |
| Please acknowledge by checking each box below that you have read, understand and agree to the following: |
I Agree: |
| I authorize the Company to investigate my background including information such as driving,
criminal, consumer credit, education, prior employment, worker's compensation and other records.
I further specifically authorize inquiries into my past employment and I direct my past
employers to give information requested as to my character, reputation, and ability. I release
those supplying any information from all liability. I also authorize this company to provide
information concerning myself and my employment to my future prospective employers. I agree
to hold it harmless for providing such information. |
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| I certify that the answers given herein are true and complete to the best of my knowledge.
I understand that any misrepresentaions, omissions of fact or incomplete answers in any application
document will disqualify me from further consideration for employment or result in my termination
if I have already been hired. |
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| I understand that my application for employment will remain on file for 30 days from the date
of the application. I further understand that, if employed, any misrpresentations or omissions of
facts in any application document will be cause for dismissal at any time without prior notice.
Although managment makes every effort to accommodate individual preferences, business needs at times
makes the following considerations mandatory: overtime, shift work, a rotation schedule other than
Monday through Friday, etc. |
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| I understand that, if employed, my employment with the company is not for a specific term and
may be terminated by me or the company with or without cause or notice at any time. I further
understand that no oral promise, employer policy, custom, business practice or other procedure
(including the Company Handbook or any personnel manuals) constitutes an employment contract for a
specific term or modification of the at-will employment relationship between me and the company. |
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| I understand that any employment offer is contingent upon successfully completing a pre-employment
drug test and background checks. |
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For security purposes please copy the digits
from the image above, into the box below... |
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