Emergency Contact Number
Employment History - Current
If yes - Name of supervisor?
Why are you leaving this place of employment
Name | Date Started / Ended | Address | Salary | Position | Reason for leaving
Name | Address | Company | Years Known
Driving Record - Upon being hired, we may consider checking to see if you have a clean driving record.
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?
Date Convicted | State offense occurred | What were you charged for?
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.