RECORD OF PREVIOUS EMPLOYMENT
Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to
account for all periods of time including military service, and any period of unemployment. If self-employed, give firm name and supply
business references, [Add additional page if necessary]. You may include any verified work performed on a volunteer basis.
Below please enter the requested information in the following format. Add as many blocks as you need in the below text input area to account for your past employment.
Employer:
Employer Address:
Employer Telephone #:
Employed From-To: (Date range of employment.)
Pay Start: $
Pay Final: $
Title or Position:
Name and Title of Last Supervisor:
Exact Reason for Leaving:
In the text area below, please list the following information for past education, including High School:
School Name:
Years Completed:
Diploma/Degree:
Describe Course Of Study or Major:
Describe Specialized Training, Experience, Skills and ExtraCurricular Activities:
In the text area below, please add the following information for any personal references. List persons who know you well - not relatives.
Name:
Occupation:
Address (Street, City and State):
Telephone Number:
Number of Years Known:
THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF NINETY (90) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.
I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION AND THE ACCOMPANYING DOCUMENTS IS TRUE, COMPLETE AND ACCURATE.
APPLICANT'S STATEMENT & AGREEMENT
In the event of my employment to a position in this Company, I will comply with all rules and regulations of this Company. I understand
that if I receive an offer of employment from the Company, the Company reserves the right to require me to submit to a test for the
presence of drugs in my system prior to employment and at any time during my employment, to the extent permitted by law. I also
understand that any offer of employment may be contingent upon the passing of physical examination. I consent to the disclosure of the
results of any physical examination and related tests to the Company in accordance with applicable law. I also understand that I may be
required to take other tests such as personality and honesty tests, prior to employment and during my employment. I understand that
should I decline to sign this consent or decline to take any of the above tests, my application for employment may be rejected or my
employment may be terminated. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after
hiring and a bond application will have to be completed.
I understand that if I receive an offer of employment from the Company, the company may investigate my driving record and my
criminal record and that an investigative consumer report may be prepared whereby information is obtained through personal interviews
with my neighbors, friends, personal references, and others with whom I am acquainted. This inquiry 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 inquiry
within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I further
understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records
and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my
employment, I hereby fully waive any right or claims I have or may have against my former employers, their agents, employees, and
representatives, as well as other individuals who release information to the Company, and release them from any and all liability, claims,
or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party,
whether such information is favorable or unfavorable to me. I authorize the persons named herein as personal references to provide the
Company with any pertinent information they may have regarding myself.
I hereby state that all the information that I have provided on this application or any other documents filled out in connection with my
employment, and in any interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably.
I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed.
If hired, I agree as follows: My employment and compensation is terminable at-will, is for no definite period, and my employment and
compensation may be terminated by the Company (employer) at any time and for any reason whatsoever, with or without good cause at
the option of either the Company or myself. No implied, oral, or written agreements contrary to the express language of this agreement
are valid unless they are in writing and signed by the President of Company (or majority owner or owners if Company is not a
corporation). No supervisor or representative of the Company, other than the President of the Company (or majority owner or owners if
Company is not a corporation), has any authority to make any agreements contrary to the foregoing. This agreement is the entire
agreement between the Company and the employee regarding the rights of the Company or employee to terminate employment with or
without good cause, and this agreement takes the place of all prior and contemporaneous agreements, representations, and
understandings of the employee and the Company.
I further understand that that Company (or majority owner or owners if Company is not a corporation) may modify, amend or terminate
any of its policies and/or benefit plans at any time, with or without prior notice. I agree to follow and be bound by the Company’s
policies, as they may be changed or modified from time to time.
If you have any questions regarding the statement, please ask a Company representative before signing. I hereby acknowledge that I
have read the above statements and understand the same.
If you have any questions regarding the statement, please ask a Company representative before signing. I hereby acknowledge that I
have read the above statements and understand the same
BY SUBMITTING THIS FORM YOU ARE AGREEING TO THE ABOVE STATEMENT & AGREEMENT
