Personal Data DATE //
Last Name
First Name
Middle Name
Telephone Number
  Address of Residence
City
State
Zip Code
Referred by
  Are you less than 18 years of age?
YesNo
Upon offer of employment, can you verify your legal right to work in the United States? YesNo Have you ever used another name?
YesNo
  Do you have a valid drivers license?
YesNo
State
Exp. Date
Currently Valid?
YesNo
Driving Record

 

EMPLOYMENT DESIRED DATE AVAILABLE // SALARY DESIRED $ per hour
Position desired or area of interest
Names of friends/relatives employed here

  Are you employed now?
YesNo
If YES, may we contact your employer?
YesNo
May we contact your previous employers?
YesNo
  Can you work overtime?
YesNo
Are you able to perform the essential functions of the job for which you are applying
for without accommodation?
YesNo

 

EDUCATION/MILITARY SERVICE
Please indicate any languages, other than English,
that you
Speak
Read
Write
  Grade School
Location
Grades Attended
Did you graduate? YesNo Grades Average
Favorite Subjects
  High School
Location
Grades Attended
Did you graduate? YesNo Grades Average
Favorite Subjects
  College
Location
Degrees/Units
Did you graduate? YesNo Grades Average
Favorite Subjects
  Other
Location
Degrees/Units
Did you graduate? YesNo Grades Average
Favorite Subjects
  Have you ever served in the U.S. Armed Services?
YesNo
If YES, Military training or duties:

 

EXPERIENCE AND EMPLOYMENT HISTORY List last four employers, starting with the last one first.
Include part-time, military, seasonal and unemployment.
From: // Employer Name Salary Position/Duties
  To: // Address Reason for leaving
  From // Employer Name Salary Position/Duties
  To // Address Reason for leaving
From // Employer Name Salary Position/Duties
  To // Address Reason for leaving
  From // Employer Name Salary Position/Duties
  To // Address Reason for leaving

 

EMERGENCY INFORMATION In case of emergency, Notify     
First Name
Last Name
Telephone Number
Relationship
Address
City
State
Zip Code
 

 

Comment Area (if needed)

 

Acknowledgement

1. I understand that if I am being considered for employment by Bland Solar & Air, I will be required to submit to a post-offer physical and drug/alcohol testing (all of which will be paid for by Bland Solar & Air, and authorize release of the physical exam and test results to Bland Solar & Air Applicants whose test results are positive (prohibited substances present) will not be eligible for further employment consideration. I will at my own expense provide a DMV report.

2. I also understand that as part of my Application for Employment that at any time during the course of such employment, I may be required to be examined concerning my ability to perform any job in a manner that does not endanger my own health or safety or the health of others. I hereby authorize all providers of health care who examine me to disclose to my employer or any of its agents, representatives and employees, including attorneys, all medical information revealed during such examinations. I further authorize my employer to disclose such information to any person if at any time my medical condition is put at issue in any proceeding by myself or others. I understand this authorization will remain valid for five years from the date of this Application, and that if I become employed this authorization will remain in effect for five years after my employment terminates. I understand that I have the right to receive a copy of this authorization. I hereby waive any and all rights and claims I may have regarding Bland Solar & Air, or its agents, employees or representatives for seeking, gathering and using such information in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

3. Any acceptance of employment will be predicated upon the truthfulness of the written and verbal statements contained within this Application and pre-employment process. I understand that should my employer find any statement I have made is not truthful, any job extended to me may be withdrawn and, if employed, I may be subject to termination.

4. I understand this Application of Employment is not to be confused as a guarantee of employment for a specific time. I further understand that my employment with Bland Solar & Air, does not constitute any form of contract, implied or expressed, and such employment will be terminable at will either by myself or my employer upon notice of one party to the other. My continued employment is dependent on satisfactory performance and the continued need for my services as determined by Bland Solar & Air

5. I grant my employer approval, after my termination of employment to release information which it may deem appropriate regarding my employment with or termination from Bland Solar & Air, to anyone who has a reasonable basis for making such inquiry. So long as the information disclosed is not known by Bland Solar & Air, to be accurate, Bland Solar & Air, shall not incur legal liability of any nature in connection with furnishing of such information.

6. I understand that my Application for Employment will be placed in an active status for a period of six months during which time it will be reviewed as job openings occur in my area(s) of job interest. I also understand that should I wish to continue being considered for job openings beyond the six month period, I must reapply by (a) submitting a new Application for Employment or by (b) submitting a letter requesting renewal of my Application and including an update of my qualifications, recent work history etc.

7. I understand that I must comply with the Drug Free Workplace Act.

I certify that I have read all of the above statements and that I understand them.

 

Type Initials Date //