Fillable Application For Employment (Page 2 of 2) in pdf

FORMER EMPLOYERS:

List below your last four employers, starting with the last one first.

Date

Phone

Salary

Reason

Name and Address of Employer

Supervisor

Position

Month and Year

Number

(upon leaving)

for Leaving

From

REFERENCES:

List below three persons not related to you, whom you have known at least one year.

Phone

Years

Name

Address

Position

Number

Acquainted

IN CASE OF EMERGENCY, NOTIFY: ___________________________________________________

Address: ________________________________________________ Phone: ____________________

If you are to be hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents

confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.

AUTORIZATION

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I

understand that any false statement, omission, or misrepresentation of this application is sufficient cause for refusal to hire, or dismissal if I have

been employed, no matter when discovered by the Company.

I understand that any employment is conditioned on a background check. I authorize the Company to thoroughly investigate all statements

contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former

employment, character and general reputation to the Company, without giving me prior notice of such disclosure. In addition, I release the

Company, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such

investigation or disclosure.

I understand and agree that nothing contained in the application, or conveyed during any interview, is intended to create an employment contract.

I further understand and agree that if I am hired, my employment will be “at will” and without fixed term, and may be terminated at any time, with

or without cause and without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to

me, and I understand that no such promise or guarantee is binding upon the Company unless made is writing by an authorize Company

representative.

If I am offered employment I agree to submit to a medical examination and drug test, if required, before starting work. If employed, I also agree to

submit to a medical examination or drug test at any time deemed appropriate by the Company and as permitted by the law. I consent to such

examinations and test and I request that the examining doctor disclose to the Company the results of the examination, which results shall remain

confidential and segregated from my file. I understand that my employment or continued employment, to the extent permitted by law, is

contingent upon satisfactory medical examinations and drug t. If required, and if I am hired a condition of my employment will be that I abide by

the Company’s Drug and Alcohol Policy.

I understand that acceptance of this form does not indicate there is a position open and not obligate the Company to hire. If hired, I agree to abide

by all Company work rules, policies and procedures. The Company retains the right to revise its policies or procedures, in whole or in part, at any

time.

Date:

Signature:

__________________________________________________

Application For Employment Page 2

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