Date
*
MM
DD
YYYY
Applicant's Name
*
First Name
Last Name
Company
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Applicants Phone
*
(###)
###
####
Emergency Contact Phone Number
*
Emergency Contact Name
*
First Name
Last Name
TO BE READ AND SIGNED BY APPLICANT
*
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my work history, including my safety performance history as required by 49 CFR 391.23 (d) and (e). I understand that I have the right to:
• Review information provided by previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
First Name
Last Name
Position Applying For:
*
Date
*
MM
DD
YYYY
Applicant's Name
Current Address
*
List your current address of residency for the past 3 years.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Previous Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Previous Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Previous Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
How were you referred to us?
*
Type of Employment
*
Full-Time
Part-Time
Temporary
Date you will be able to start work.
*
MM
DD
YYYY
Are you able to meet the attendance requirements?
*
Do you have any objection to working overtime if necessary?
*
Can you travel if required by this position?
*
Have you ever been previously employed by our organization?
*
Can you submit proof of legal employment authorization and identity?
*
If you are under 18, can you furnish a work permit if it is required?
*
Have you ever been convicted of a crime in the last 7 years?
*
If yes, please explain (a conviction will not automatically bar employment):
Drivers License number (if driving is an essential job duty):
*
Employer 1:
*
Position Held:
*
Employer 1 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer 1 Phone Number
*
(###)
###
####
Immediate Supervisor's Name and Title:
*
Dates Employed (Start Date to End Date):
*
Beginning Salary:
*
End Salary:
*
Can we contact this employer?
*
If marked no explain why:
Job Summary:
*
Reason for Leaving:
*
Employer 2 Phone Number
*
Position Held:
*
Employer 2 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer 2 Phone Number
*
(###)
###
####
Immediate Supervisor's Name and Title:
*
Dates Employed (Start Date to End Date):
*
Beginning Salary:
*
End Salary:
*
Can we contact this employer?
*
If marked no explain why?
Job Summary:
*
Reason for Leaving:
*
Employer 3
Position Held:
Employer 3 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer 3 Phone Number
(###)
###
####
Immediate Supervisor's Name and Title:
Dates Employed (Start Date to End Date):
Beginning Salary:
End Salary:
Can we contact this employer?
If marked no explain why?
Job Summary:
Reason for Leaving:
Employer 4
Position Held:
Employer 4 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer 4 Phone Number
(###)
###
####
Immediate Supervisor's Name and Title:
Dates Employed (Start Date to End Date):
Beginning Salary:
End Salary:
Can we contact this employer?
If marked no explain why?
Job Summary:
Reason for Leaving:
Explain any Gaps in Employment:
Other Skills and Qualifications:
Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:
High School
*
Name of School and Location
Did you graduate High School?
Yes
No
College
Name of School, Location, Year Completed, Course of Study, Degree Earned
Technical Training
Name of School, Location, Year Completed, Course of Study, Degree Earned
Other
Reference 1
*
First Name
Last Name
Reference 1 Phone Number
*
Number of Years Known
*
Reference 2
*
First Name
Last Name
Reference 2 Phone Number
*
Number of Years Known
*
Reference 3
*
First Name
Last Name
Reference 3 Phone Number
*
Number of Years Known
*
Applicant Signature:
*
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.
I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.
If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminated the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.
I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA.
I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.
I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.
I understand that this employer requires every prospective employee that is being offered employment to submit to a pre-employment drug test.
I UNDERSTAND THAT EFT (ELECTRONIC FUNDS TRANSFER) (IE PAYROLL DIRECT DEPOSIT) IS A REQUIREMENT FOR MY BEING HIRED. I UNDERSTAND I MUST PROVIDE THE NECESSARY BANKING INFORMATION ON THE FORM I COMPLETE WITH ALL OF MY OTHER EMPLOYMENT PAPERWORK. I UNDERSTAND THAT IF THE EFT (ELECTRONIC FUNDS TRANSFER) PAPERWORK IS NOT RETURNED ALONG WITH MY OTHER PAPERWORK AT MY TIME OF HIRE, I WILL BE TERMINATED FOR FAILURE TO COMPLY WITH THIS CONDITION OF EMPLOYMENT.
First Name
Last Name
Date:
*
MM
DD
YYYY
Do you have the right to work on the United States?
*
