Job Applied For:
Date
What type of employment are you seeking?
When can you start work?
Your Full Name
Full Street, City, State Address
Phone Number
Email Address
Are you 18 years of age or older?
(If you are hired, you may be required to submit proof of age.)
If Hired, can you furnish proof you are eligible to work in the US?

Have you ever applied here before?
If yes, when?
Were you ever employed here?
If yes, when?

WORK HISTORY

List names or employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If Self-employed, give firm name and supply business references.
PLEASE GIVE MONTH AND YEAR.

Click on the "+" below to add more Employer Blocks


EDUCATION


List all Names and Addresses of each School attended.

Click on the "+" below to add more Education Levels. Select a new educational level for each new block you add.


SPECIAL SKILLS

What skills or additional training do you have that are related to the job for which you are applying?
What machines or equipment can you operate that are related to the job for which you are applying?
How many days of work have you missed in the past year? (Exclude absences due to disability or those covered by FMLA)
List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal race, color, religion, national origin, sex, age disability or other protected status.)
For Driving Jobs Only: Do you have a valid Driver's License?
Driver's License Number
Have you had your Driver's License suspended
or revoked in the last 3 years?
If yes, give details


REFERENCES

Have you worked or attended school under any other name?
If yes, give names:
Are you presently employed?
If yes, whom do you suggest we contact?
Have you ever been fired from a job or asked to resign?
If yes, please explain:
Give three references, employers and/or co-workers please


AFFIDAVIT

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from futher consideration for employment and may result in my dismissal if discovered at a later date.

I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my charactor, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of investigation.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, andorganizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that if I am extended and offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre-and/or post- drug screen as a condition of employment, if required.

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITH OUT CAUSE OR WITHOUT NOTICE.

I have read, understand, and by my signature consent to these statements.

Digital Signature
Last 4 digits of SS#
Date
This application for employment will remain active for a limited time. Ask Peritech's representative for details.