Employment Application

    This is a Drug-Free Workplace Offering Equal Employment Opportunities. Applications are received and employees are hired without regard to race, color, sex, religion, age, genetic information, national origin, disability, veteran’s status, citizenship status, or any other protected classes under state, local, or county regulations. The receipt of this application does not mean that job openings exist and does not obligate us in any way. We appreciate your interest in our organization.

    Your Personal Information


    Home Phone:

    Cell Phone:






    Preferred method of contact:

    Your Work History And Any Employment Gaps

    Must be completed even when accompanied by resume. List most recent or current job first. You must include any gaps in employment, with a full explanation and dates for the gap. You must also provide a complete work history for a minimum of seven years. If you need more space, photocopy page 2 or fill out a separate page and attach it to this form.

    Employer #1


    Address (City, State, Zip):


    Start Date:

    End Date:

    Job Title:

    Supervisor’s Name:

    Summary of Work Performed & Job Responsibilities:

    State Reason:

    Employer #2


    Address (City, State, Zip):


    Start Date:

    End Date:

    Job Title:

    Supervisor’s Name:

    Summary of Work Performed & Job Responsibilities:

    State Reason:

    Employer #3


    Address (City, State, Zip):


    Start Date:

    End Date:

    Job Title:

    Supervisor’s Name:

    Summary of Work Performed & Job Responsibilities:

    State Reason:

    Tell Us About Yourself

    You must answer every question on this application. If a question does not apply, put "N/A".

    What position are you applying for?

    What are your pay expectations?

    When can you start work?

    How were you referred to us? (If you were referred by a person, please provide the name)

    Have you completed an application here before?

    If yes, date/location:

    Have you been employed here before?

    Yes No If yes, date/position/location:

    Are you available to work (Check any that apply):

    Are there any days or times during the week that you are not available to work?

    If yes, please list the days/times you are not available to work:

    If necessary, can you provide proof that you are over any minimum work age requirement?

    Are you willing to work overtime?

    Do you have steady transportation to work?

    What percentage of the time can you travel?

    Are you on a layoff and subject to recall?

    May we contact your present employer?

    How much time have you lost from work in the past 12 months?

    Are you now, or do you expect to be, engaged in any other business or employment while working here?

    If yes, please explain.

    Are you presently an officer, employee, or employer of another business in our industry or with whom we compete?

    If yes, please explain.

    Please list any business that you own or have a majority interest in.

    Have you ever been terminated from employment or asked to resign from a job?

    If yes, please explain.

    Why do you desire to make a change?

    Are you legally eligible to work in the United States? (Proof of status/identity required upon hire)?

    What three things are most important to you in a job?

    What three adjectives best describe you?

    Why type of work do you most enjoy?

    Why do you want to work here?

    Have you ever been a customer of ours?

    If yes, what services did you receive?

    Tell Us About Your Special Skills and Qualifications

    List any special skills, training, experience, certifications, or licenses that may be relevant to this position or our company

    List any professional, trade, business, or civic activities or offices held that would relate to working here

    List any foreign languages that you fluently speak, read, and/or write that would relate to working here

    List software programs that you are proficient in

    Your Educational Background


    Did you Graduate

    Years Completed

    Degree received and major subject

    Name of School


    High School or GED

    Trade, Business, or Correspondence


    Graduate School

    Tell Us About Your Driving Record

    Necessary for positions that may require use of a personal or company vehicle for work

    Do you hold a valid and unexpired Driver’s License that is not currently suspended or revoked?

    If yes, please provide the state.

    Have you been convicted of any moving violation(s) in the last 5 years?

    Yes No If yes, give date(s) and explanation of each:

    Military Service

    Branch of service?

    Rank at discharge?

    Dates from to

    List Duties and Special Training and/or Skills

    Non-Compete Agreement

    Are you currently subject to a Non-Compete Agreement or Restrictive Covenant that would prohibit you from working at our company in the position for which you are applying?

    If yes, provide a copy of the agreement and state the name of the company:

    Tell Us About Your Past

    Answering “yes” to any of these questions is not an automatic bar to employment.

    Have you ever had any professional license or certificate suspended or revoked (e.g., pest control operator’s license, law license, real estate license, etc.)?

    If yes, list the professional license(s) and/or certificate(s) that were suspended or revoked and state when and why the license(s) and/or certificate(s) were suspended or revoked

    Agreement and Release

    For the purpose of this agreement and release, the organization that has provided you with this application is referred to as “the company,” “this company,” or “you” in the following paragraphs:

    The facts set forth above in my application for employment are true and complete. I understand that false statements or omission of information on this application (even if discovered after employment) or any other employment form may lead to dismissal or denial of employment. You are hereby authorized to make any investigation of my personal history, financial, criminal, credit, and motor vehicle records through any investigative or credit agencies or bureaus of your choice. You are also authorized to administer a personality profile or other pre-employment tests and verify my background. A criminal record or sentence is not an automatic disqualification for employment. I agree to submit to any drug or alcohol testing prior to or after employment.

    In making this application for employment, I also understand that an investigative consumer report may be made whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. I also acknowledge that the company may conduct a search for information about me that is in the public domain, including, but not limited to, information on social networking sites. In exchange for the consideration of my employment application by this company, I hereby release and forever discharge this company (including its directors, officers, employees, and agents) and my past and/or present employers (including their directors, officers, employees, and agents) from any liabilities which may result from an investigation of my past and/or present employment or from the disclosure of such information. I authorize the use of any information in this application to verify my statements, and I authorize past employers, doctors, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record.

    I understand that if my application is accepted and if I am hired, employment with this company at all times is employment “at will.” It is further understood that this “at will” relationship may not be changed by any written document, verbal statements, or by conduct unless an authorized executive of this company specifically acknowledges such change. I further understand that my “at will” employment may be terminated at any time by this company or myself and includes no guarantee, contract, or promise of employment for any specific length of time. I understand that the first 90 days of employment is a new-hire introductory period. Submission of this application does not imply that I will be hired.

    Attach Relevant Files (Application, documents, etc)

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