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Employment Application

Personal Information

Name:

Present Address:
City:
State:
Zip:

Permanent Address:
City:
State:
Zip:

Phone Number: () -
Secondary Phone Number: () -

Referred By:

Employment Desired

Position:
Date You Can Start:
Salary Desired:
Are You Employed Now:
If so, may we inquire with your present employer:

Ever applied to this company before:
Where:
When:

Education History

High School (name & location):
Years Attended:
Did You Graduate:
Subjects Studied:

College (name & location):
Years Attended:
Did You Graduate:
Subjects Studied:

Trade, Business, or Correspondence School (name & location):
Years Attended:
Did You Graduate:
Subjects Studied:

General Information

Do You Have a Valid Driver's License:
Subject of Special Study/Research Work:
Special Training:
Special Skills:

U.S. Military or Naval Service:
Rank:

Former Employers (list four, staring with most recent)

Dates (Month & Year): to
Employer Name & Address:
Salary:
Position:
Reason for Leaving:

Dates (Month & Year): to
Employer Name & Address:
Salary:
Position:
Reason for Leaving:

Dates (Month & Year): to
Employer Name & Address:
Salary:
Position:
Reason for Leaving:

Dates (Month & Year): to
Employer Name & Address:
Salary:
Position:
Reason for Leaving:

References (list three persons not related to you, whom you have know at least one year)

Name:
Address:
Business:
Years Known:

Name:
Address:
Business:
Years Known:

Name:
Address:
Business:
Years Known:

 

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disablities Act (ADA) and other relevant federal and state laws.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment."

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

 


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Office Phone: 304.233.5566 or Toll Free 800.964.2929
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