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Name:(Last Name First):
Secondary Phone No.:
Date You Can Start:
Are You Employed Now?
If So, May We Inquire of Your Present Employer?
Are You Legally Authorized to Work in the U.S.?
Ever Applied to this Company Before?
Name & Location of School
Did You Graduate?
Trade, Business, or Correspondence School
Subject of Special Study/Research Work:
U.S. Military or Naval Service:
Former Employers (List Below Last Four Employers, Starting with the Last One First)
Date: (Month and Year)
Name & Address of Employer
Reason for Leaving
(Below, Give the Names of Three Persons Not Related to You Whom You Have Known at Least One Year)
"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 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 liablility forany damage that may result from utilization of such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to mak any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
This waiver does not permit the release or use of disability-relatied or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."
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