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Employment Application Form
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Name (First, Middle & Last)
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Date
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Desired Salary
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Social Security Number
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Date of Birth
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Street Address
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City
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State
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Zip Code
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How Long At Address?
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Home Phone
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Cell Phone
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If time at current address is less than 3 years, please fill in previous address and how long you lived there for.
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Date Available to Begin Work
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Marital Status
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No. of Dependents
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Are you over 18 years of age?
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Yes
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No
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Are you eligible to work in the United States?
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Yes
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No
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Do you have a valid driver's license?
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Yes
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No
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If yes, issued by what state?
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If yes, driver's license number.
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Do you have reliable transportation to and from work?
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Please describe your driving record.
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Have you ever been arrested?
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Yes
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No
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If yes, for what?
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What is the last grade that you successfully completed in school?
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Do you have a college education?
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Yes
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No
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If yes, what courses did you take?
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General Information
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Do you have experience in any of the following?
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A/C & Heat
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Appliances
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If yes to any of the above, please describe.
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Do you have any other work experience or certifications?
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Employment History
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Current or most recent employer
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*Address
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*Phone Number
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*Dates employed (From - To)
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Duties Performed
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Reason for leaving
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Immediate Supervisor
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May we contact?
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Yes
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No
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Previous Employer
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Address
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Phone Number
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Dates employed (From - To)
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Duties Performed
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Reason for leaving
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Immediate Supervisor
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May we contact?
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Yes
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No
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Previous Employer
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Address
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Phone Number
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Dates employed (From - To)
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Duties Performed
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Reason for leaving
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Immediate Supervisor
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May we contact?
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Yes
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No
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Personal Reference
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Name
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Phone Number
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Relationship
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Address
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Name
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Phone Number
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Relationship
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Address
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"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 concerning my previous employment and any pertinent information they my have, personal or otherwise, and release the company from all liability for any 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 agreegment for employment for any specified period of time, or to make 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-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."
Applicant's Electronic Signature (By typing in your name this will be used as your online signature)
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Date - App
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