APPLICATION FOR EMPLOYMENT

We are an equal opportunity employer. Race, Color, religion, age, sex and national origin are not factors in employment, promotion and compensation. Please read and check the acceptance box for the Applicant's Statement, and the Disclosure to Obtain a Credit Report at the end of this application.

PERSONAL INFORMATION 
Name   
(First)
(Middle)
(Last)		 Home telephone Number

 
Home Address    
(Street)
(City)
(State)
(Zip)		 Business or Msg Phone

 

 
Are you a U.S. citizen or are you authorized by the INS to work?
 Yes No		 Social Security Number
Are you between the ages of 18 - 70? 
Yes No		 Who referred you to us?
Agency Employee Ad Other:
Have you been convicted of a felony? 
Yes No
If yes, please explain 

A YES STATEMENT DOES NOT NECESSARILY BAR YOU FROM EMPLOYMENT

 
Have you applied for employment here before? Yes NoWhen?
 Where? 		Date you can start

 
Have you ever been employed here?
Yes NoWhen?
Where?		 Starting salary desired
Are you employed now? Yes No
If so, may we contact your employer? 
Yes No		 Position Desired
Are you currently on layoff or leave from another company? Yes No List Applicable Skills
Are you willing to travel? Yes No
 If so, % of time.
Are you willing to relocate? Yes No 
Are you available for full -time work?
Yes No
 Are you available for part time work?
Yes No

Education
Name of School  Location
City State		 Main Course of Study Did you Graduate? Grade Average Degree/Diploma
Yes
No
Yes
No
Yes
No
Yes
No
List any scholastic honors received and offices held while in school 
Are you planning to pursue other studies?
Yes NoDay Night
If so, where and what course of study?

Employment History (List employment for the last 10 years, starting with present job. Include military experience.)
Company 1 Name
 Specific Duties
Street Address
 Telephone
City & State
,
Job Title
 Reason for Leaving
Supervisor
Dates Employed 
(from)
(to)		 Salary
Company 2 Name
 Specific Duties
Street Address
 Telephone
City & State
,
Job Title
 Reason for Leaving
Supervisor
Dates Employed 
(from)
(to)		 Salary
Company 3 Name
 Specific Duties
Street Address
 Telephone
City & State
,
Job Title
 Reason for Leaving
Supervisor
Dates Employed 
(from)
(to)		 Salary
Company 4 Name
 Specific Duties
Street Address
 Telephone
City & State
,
Job Title
 Reason for Leaving
Supervisor
Dates Employed 
(from)
(to)		 Salary
Company 5 Name
 Specific Duties
Street Address
 Telephone
City & State
,
Job Title
 Reason for Leaving
Supervisor
Dates Employed 
(from)
(to)		 Salary

IF YOU NEED ADDITIONAL SPACE PLEASE CUT AND PASTE INFORMATION INTO THE SCROLLING TEXT BOX PROVIDED


REFERENCES List 2 people not related to you who have known you for 1 year.

 

Name

Address

Business

Years Acquainted

APPLICANT'S STATEMENT (Please read carefully):
I understand that, if I am hired, my employment will be "at will", meaning that I can terminate or can be terminated at any time with or without cause.

I understand that the company requires a pre-employment drug test and reserves the right to drug test at anytime. l understand that if I am offered this position any employment will be contingent upon (1) completion of a medical questionnaire, (2) if applicable, completion of a follow-up medical examination, and if applicable, completion of a certificate of pre-existing physical impairment. I understand that the company may require that medical information be updated at any time. I consent to disclosure of this information to the company. I UNDERSTAND THAT I WILL NOT BE ENTITLED TO FUTURE WORKERS' COMPENSATION BENEFITS IF I KNOWINGLY AND WILLFULLY CONCEAL OR MAKE FALSE REPRESENTATION ABOUT MEDICAL INFORMATION.

I agree that any money I owe the company ( including monthly insurance premiums, purchases, uniform rental and demo charges) will be deducted from my payroll checks. I understand that all of the company's customer lists and other customer information is confidential and belongs to the company. I will not remove this information from company premises or make personal use of it. I agree to return all uniforms, equipment, tools, supplies, keys and other company property to the company before I receive my final paycheck.

I consent to a credit bureau check by the company at any time, and I understand that the company may investigate my employment record, criminal record, driving record, and other background information about me at any time. I understand an investigative consumer report may be made whereby Information is obtained through personal Interviews with my neighbors, friends and others with whom I am acquainted. This 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 time to receive additional detailed information about the nature and scope of this investigation. I agree to a pre-employment interview wih a third party if requested by the company and to take any requested tests including personality and honesty tests. I authorize my previous employers and references to disclose any information and records about me to the company. I release them and their representatives from any claims related to such disclosure.
I understand that this application will be considered, but is not a promise of employment. I understand that this application will be active for a maximum of 30 days, and that if I wish to be considered thereafter I must re-apply.

I certify that all of the information provided in this application and in any interview is True and complete I acknowledge that if I am employed and any of this information is found to be false in any respect at any time, I will be subject to immediate termination.

I have read and agree to the above Applicant's Statement.

Disclosure of Intention To Obtain A Credit Report

In accordance with The Fair Credit Reporting Act section 604 (b) (2) (A), Experian may obtain a credit report on all individuals who apply for new employment or promotions.
I have read and agree to the above Disclosure of Intention to Obtain a Credit Report.

 
Copyright 2005 Money Processing Systems, Inc. All Rights Reserved.