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Lynchburg: 434.455.1212

Employment

Last Name(*)
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Middle Initial(*)
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First Name(*)
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Social Security #(*)
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Present Address(*)
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Home Phone
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Cell Number(*)
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Emergency Contact Number(*)
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Your Age(*)
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Employment History - Current

Employer:
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Position:
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Are you employed:(*)
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May we contact your current employer?(*)
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If yes - Name of supervisor?
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Why are you leaving this place of employment
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Former Employers

Name | Date Started / Ended | Address | Salary | Position | Reason for leaving
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References

Name | Address | Company | Years Known
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Driving Record - Upon being hired, we may consider checking to see if you have a clean driving record.

State Issued(*)
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License #
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Current?
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Suspended?
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Criminal Record - Upon being hired, we may consider checking to see if you have a criminal record.

Have you ever been convicted of a felony?(*)
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Date Convicted | State offense occurred | What were you charged for?
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Authorization 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 the 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 authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the forgoing, unless it is in writing an 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 American with Disabilities Act (ADA) and other relevant federal and state laws.

I Agree(*)
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I would just like to say a big THANKS to Collegiate Movers for helping me to get moved. The guys were professional, courteous and I felt like they treated my things as they would have treated their own. I just can't say enough good things about them. I would highly recommend them to anyone.

Phyllis Williams