Application Form

Personal Information:

First Name
Middle Name
Last Name
Social Security Number
Present Address (Street, City, State, Zip)
What position are you applying for?
Do you have adequate transportation to work?
Does your immigration status permit you to accept employment lawfully, immediately, and indefinitely?
If not, what must be done in order for you to accept or continue the proposed employment lawfully?
Have you been convicted of, or pled guilty, no contest to, or received deferred adjudication for a felony or misdemeanor?
If yes, please describe in full.

Employer Information:

Most Recent Employer

Employer Name
Kind of Business
Employer Phone Number
Employer Address (Street, City, State, Zip)
Supervisor Name and Title
Starting Date
Starting Title
Starting Pay
Ending Date
Ending Title
Ending Pay
Reason for leaving
May we contact your employer now without jeopardizing your position?

Application Agreement

I hereby certify that the information I have provided on this application (and any other document I have provided) is true, correct, and complete. I understand that any falsification, misrepresentation or omission in this application or hiring process will be sufficient grounds for rejection of the application or termination of employment without notice at any time hereafter. I understand that, as part of the pre-employment process, an investigative consumer report may be obtained by the company, including information as to my character, general reputation, personal characteristics and mode of living. Upon my written request, within a reasonable time from the date of this application, additional information as to the nature and scope of the investigation and report, if any, will be provided. I hereby release all persons furnishing information in connection with the investigative consumer report from liability or damages incurred as a result of such an inquiry and furnishing of this information. I herby authorize any and all schools, former employers, references, courts, and any others who have information about me to provide such information to the company and/or any of its representatives, agents, or vendors, and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that if offered a position, I will be required to submit to a pre-employment health survey, which may include drug screening. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. In consideration for employment by the company, if employed, I agree to conform to the rules, regulations, policies and procedures of the company at all times and understand that such obedience is a condition of employment If employed, I understand that I retain my normal right to terminate any employment relationship at any time, with or without any notice or reason, and I understand that the company retains the same right. I also recognize that nothing shall alter the terminable-at-will nature of my employment relationship with the company unless it is in writing and signed by the president of the company. I agree that in consideration of my employment with the Company that if I file a lawsuit regarding the conditions of my employment or termination of employment, I will waive my right to a jury trial and that no demand, request or motion will be made for trial by jury. Instead, I agree that the case will be tried to a judge without a jury. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.

Please type your full name in the box below: