Personal References
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1
2Personal References
List three persons, not related to you, whom you have known for at least one year.
(Examples: Teachers, coaches, etc.)
Name
Address and Phone Number
How do you know this person?
1. ________________
______________________
__________________
2. ________________
______________________
__________________
3. ________________
______________________
__________________
If the company hires you, 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 complete
these requirements.
Authorization
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 on the applica-
tion 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 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.
If I am offered employment I agree to submit to a medical examination and drug test 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 law. I consent to such examinations and tests, 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 personnel file. I understand that my employment, to the extent permitted by law, is contin-
gent upon satisfactory medical examinations and drug test, 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 filling out this form does not indicate there is a position open and does not obligate the Com-
pany to hire. If hired I agree to abide by all Company work rules, policies, and procedures. The Company
retains the right to revise it's policies and procedures, in whole or in part, at any time.
Date ______________________________ Signature ____________________________________________
Interviewed by __________________________________________________________________________
REMARKS
Do not write below this line
Neatness _________________________________ Character _______________________________________
Personality _____________________________ Ability ____________________________________________
Hired _____________________________________________________________________________________
For
Department
Position
Will Report
Salary / Wages
Approved _________________________________________________________________________________
Employment
Manager
Department
Head
General
Manager
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Parent category: Letters