Job Application

It is the policy of this company to provide equal employment opportunity to a qualified applicant without regard to race, color, religion, sex, sexual orientation, national origin, age, marital status, veteran status, non-job disability, or any other protected group status. The Company to which you are applying for employment strives to maintain a drug and alcohol free workplace. We reserve the right to administer our substance abuse policy and to test candidates prior to hiring them for prohibited drugs and/or alcohol.

Position Applying For

Date

Personal Information

Nameyour full name

Full Address

0 /

Emaila valid email

PhoneBest # to reach you

Date available to work

Do you have a valid driver's license?

YesNo

Statefor license

Classfor license

Are you a U.S. Citizen or otherwise authorized to work in the United States on an unrestricted basis?

YesNo

How did you learn of our organization?

0 /

Have you ever applied for employment with us?

YesNo

If yes, month, year, and position

0 /

State names of relatives and friends working for us.

0 /

Have you been convicted of a crime in the past ten years, which has not been annulled, expunged or sealed by a court?

YesNo

If you answered yes, explain in full:

0 /

Education

High SchoolAttended

High School Address

0 /

Course of Study

Numbers of YearsCompleted

Did You Graduate HS?

YesNo

Degree/Diploma

College/UniversityAttended

College/University Address

0 /

Course of Study

Numbers of YearsCompleted

Did You Graduate College/University?

YesNo

Degree/Diploma

Technical/VocationalAttended

Technical/Vocational Address

0 /

Course of Study

Numbers of YearsCompleted

Did You Graduate Technical/Vocational?

YesNo

Degree/Diploma

Military

Branch of Service

Active DutyYears

0 /

Date of Discharge

Rank at Discharge

Describe your duties and any special training

0 /

Employment

Employer 1

Phone number

Address

0 /

Position

Rate of pay

Dates of Employment

0 /

Name of Supervisor

Reason for leaving?

0 /

If Commercial driver, subject to FMCSR while employed?

YesNo

Subject to Drug and Alcohol testing?

YesNo

Job title and description of duties

0 /

Employer 2

Phone number

Address

0 /

Position

Rate of pay

Dates of Employment

0 /

Name of Supervisor

Reason for leaving?

0 /

If Commercial driver, subject to FMCSR while employed?

YesNo

Subject to Drug and Alcohol testing?

YesNo

Job title and description of duties

0 /

Employer 3

Phone number

Address

0 /

Position

Rate of pay

Dates of Employment

0 /

Name of Supervisor

Reason for leaving?

0 /

If Commercial driver, subject to FMCSR while employed?

YesNo

Subject to Drug and Alcohol testing?

YesNo

Job title and description of duties

0 /

Have you ever been discharged or reprimanded for violating a safety policy?

YesNo

If you answered yes, explain in full

0 /

Please describe any special training or skills (languages, machine operations, etc.)

0 /

References

Reference 1 Name

Reference 1 Phone

Reference 2 Name

Reference 2 Phone

Reference 3 Name

Reference 3 Phone

I certify that any answers and statements on this application form and any supplemental forms are true and complete to the best of my knowledge. If employed, I understand that any false statements or omission of facts on this application will be considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of my prior education, employment history, driving record, safety performance history or other information that may be necessary in arriving at an employment decision. Furthermore, I understand that if I am hired, employment with this company is “at will”, which means that either the company or I can terminate employment for any reason not prohibited by state or federal law. I confirm that this form has been completed by me.

Acknowledgement

Job Application

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