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Application for Employment
Social Security No.:
Are you 18 years or older?
If less than five years @ present address
If related to who works for the company, State name, Department and Location
In case of emergency, please notify
Date you can start
Are you Employed now?
May we enquire of your present employer?
Ever applied to this company before?
Are there any days, shifts or hours you will not work?
If yes, please explain
Name and Location of school
Responding "yes" to any of the below does not automatically disqualify your application; however, failure to provide complete and accurate information in response to the following questions will result in denial or termination of employment, whenever discovered. In considering your conviction record, we will only consider job-related factors, including but not limited to the date and nature of the offense.
Have you ever been convicted of, or pled guilty, no contest or nolo contendere to a crime?
If Yes, give details (date, place, offense(s), penalty imposed, disposition, etc.):
Have you ever been charged with a crime and either been placed on a court-order probation, had adjudication withheld, or entered a pre-trial intervention program?
If Yes, give details (date, place, offense(s), disposition, etc.):
Have you ever been a defendant in a civil action for intentional tort(s) (e.g assault, battery, intentional infliction of emotional distress), or an unlawful employment practice (e.g-sexual or racial harassment)?
If Yes, identify the alleged intentional tort(s) and/or unlawful practice, the disposition of the action, and the date of the disposition
List below sequentially ALL of your employers beginning with your current or most recent employer.
Date, Month and Year
Name, Address and Phone # of Employer
Position and job Duties
Reason for Leaving
Did you work for any of these employers under a different name?
If Yes, which employer(s)? Under what name?
Please explain any gaps in your employment history
Have you received any written reprimands or disciplinary suspensions during any previous employment?
If yes, please explain
Have you ever been discharged or asked to resign?
If yes, please explain(include by whom, when and for what):
Complete this section only if you are applying for a position which involves driving a Company vehicle or driving for Company business on a regular basis.
Do you have a valid driver's license?
What class of license do you possess?
Have you ever had your license and driving privileges revoked, suspended, or placed on probation?
If yes, please explain(include when, where and what action was taken):
How many speeding or other moving violations have you received in the last three (3) year(s)?
List below all trafic violations (except parking) on your records for the last five (5) years and all motor vehicles accidents in which you were involved.
Give below the name of three persons not related to you, whom you have known at least one year
Terms and Conditions
I hereby certify that all of the facts and information listed on this employment application are true and complete. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection of this application. I also understand and agree that any such false, incomplete, or misleading information discovered on this application at any time after I am employed may result in my dismissal. I hereby authorize the Company to investigate all statements contained in this application and to interview the references and previous employers listed in this application. I authorize the references and previous employers listed to give the Company all facts, opinions and evaluations concerning my previous employment and any other information they may have, personal or otherwise, and release all such parties from any liability which may allegedly arise from furnishing such information to the Company, including, but not limited to, any liability for defamation or invasion of privacy. I also authorize the Company to conduct and/or obtain a criminal records check and to obtain any available driving record from the Department of Motor Vehicles. If I am offered employment, I understand that such an offer will be conditioned upon satisfactory results of a background investigation and/or Company medical examination or inquiry, including a drug screen test. If then employed, I understand that I will be required to serve a ninety (90) day probationary period. I further understand that my employment and compensation can be terminated, with or without cause or notice, at any time, regardless of the successful completion of my probationary period, at the option of either the Company or myself. I understand that no supervisor or other representative of the Company other than the President 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. I also understand that any agreement by the President would be in writing. I further understand and voluntarily agree as a condition of employment or my continued employment that I may be requested by the Company to submit to a urinalysis or other drug screen test, and that my failure to take such test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am then employed, may result in my immediate dismissal.
I agree to the terms and conditions