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Application for Employment

PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER

Employment Application

Please complete the form below to be considered for employment.

First Name *

Last Name *

Date of Birth *

Email *

Phone *

Address Line 1 *

Address Line 2 (Apt/Unit)

City *

State *

Zip *

Date Available *

Desired Salary

Are you a citizen of the United States? *

If no, are you authorized to work in the U.S.?

Desired Position? *

Are you willing to work overtime? *

Have you ever worked for this company? *

If so, when?

Have you ever been conflicted of a felony? *

If yes, explain:

Education & Certification

Please start with your most recent education.

School/Institute *

Major/Certification Received *

Start Year

End Year

School/Institute

Major/Certification Received

Start Year

End Year

School/Institute

Major/Certification Received

Start Year

End Year

Work Experience

Please start with your most recent or current position.

Employer *

Job Title *

Address *

City *

State *

Zip *

Supervisor *

Supervisor's Phone

Start Date *

End Date

Reason for Leaving

Responsibilities

Employer

Job Title

Address

City

State

Zip

Supervisor

Supervisor's Phone

Start Date

End Date

Reason for Leaving

Responsibilities

Employer

Job Title

Address

City

State

Zip

Supervisor

Supervisor's Phone

Start Date

End Date

Reason for Leaving

Responsibilities

Skills and Qualifications

Professional References

Please list three professional references.

Name *

Relationship *

Company/Title *

Phone *

Name

Relationship

Company/Title

Phone

Name

Relationship

Company/Title

Phone

Transportation & Availability

Do you have dependable transportation? *

Can you be called at the last minute in case of emergency? *

Number of hours would you like to work? *

Military Service

Have you had any prior military service *

Branch

Dates of Service

Rank at Discharge

Type of Discharge

If other than honorable, explain

I certify that the information provided herein is true and correct to the best of my knowledge. I understand that, if employed, falsified statements on this Application for Employment form will be considered grounds for termination.

I understand that I may be required to supply my birth certificate or other proof of authorization to work in the United States, consent to a drug test, and/or sign a conflict of interest agreement and abide by its terms.

I authorize the company to thoroughly investigate my work experience and any other matters related to my suitability for employment. I further authorize my former employers to disclose to the company any and all information they may have concerning my previous employment. In addition, I hereby release Dri-Tex Restoration, my former employers, and all other persons from any and all claims, demands, or liabilities arising out of, or in any way related to such disclosure.

I acknowledge that, if employed, both Dri-Tex Restoration and I have the right to terminate the employment relationship at any time, with or without cause or advance notice. This employment at will relationship will remain in effect throughout my employment with Dri-Tex Restoration and may not be modified by any oral implied agreement.

Name *

Electronic Signature *

Date *