First
Middle
Last
Email
Phone
Street Address
City
State
Zip
How long have you lived at this address?
If no, please state your age
Employment Information
Position applying for:
Date available to start:
Referred By:
Wage desired
If yes, please identify:
If yes, When?
In connection to a criminal offense, have you ever been convicted, pled guilty, served probation, had adjudication deferred, or participated in a pre-trial diversion or other ptram?
If yes, please list the dates and court locations.
Disposition Information: The disclosure of a prior criminal justice system involvement will not necessarily affect your employment opportunity.
In the event of an Emergency, Notify:
Name
Address
Phone
Relationship
High School:
Years Completed
Degree Earned
College:
Years Completed
Degree Earned
Graduate School:
Years Completed
Degree Earned
Trade, Business, or Correspondence School:
Years Completed
Degree Earned
Please give an accurate and complete full/part time employment record. Start with your present or most recent employer first.
Company Name
Phone
Address
Employed From
To
Name of Supervisor
Starting Salary/Wages
End
Job title and responsibilities
Reason for leaving
Company Name
Phone
Address
Employed From
To
Name of Supervisor
Starting Salary/Wages
End
Job title and responsibilities
Reason for leaving
Company Name
Phone
Address
Employed From
To
Name of Supervisor
Starting Salary/Wages
End
Job title and responsibilities
Reason for leaving
Note that all the employers listed above will be contacted unless the applicant indicates differently
If yes, please indicate employer and reason:
List below the names of three persons, not related to you, whom you have known for at least one year.
Name
Address & Phone
Business
Years Known
Name
Address & Phone
Business
Years Known
Name
Address & Phone
Business
Years Known
Background Check Authorization for Consumer Reports
In connection with your application for employment (including contract for services), understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on you including consumer credit, criminal records, driving record, education, prior employer verification, workers’ compensation claims and others. These reports will include experience information along with reasons for termination of past employment. Further, understand that information from various Federal, State, local and other agencies which contain your past activities will be requested. A consumer report containing injury and illness records and medical information may be obtained only after a tentative offer of employment has been made. By signing below, you hereby authorize without reservation, any party or agency contacted by Hood Specialist, Inc. dba Facilitec Southwest to furnish the above-mentioned information. You further authorize ongoing procurement of the above-mentioned reports at any time during your employment (or contract). You also agree that a fax or photocopy of this authorization with your signature be accepted with the same authority as the original. You have the right to make a request upon proper identification and the payment of any legally permissible fees, for the information on you at the time of your request. You hereby authorize and request, without reservation, any present or former employer, school, police department, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or regarding you, in order that your employment qualifications may be evaluated.
Drivers License
Drivers State
I hereby reaffirm that I have read the foregoing questions and that my answers to them are true and correct and that I have not misrepresented or withheld any information. I understand that falsification of this information may be cause for immediate dismissal. I further acknowledge that my employment may be terminated, and the company or I
may withdraw any offer of employment without prior notice. I also understand that my employment is at will. This means I am free to terminate my employment at any time, for any reason, and the company retains the same right. I understand that any offer of employment may be contingent upon a credit and criminal background investigation
and a pre-employment drug screen. I hereby authorize all references and former employers listed on my employment application to give the company any and all information concerning my previous employment and any pertinent information they might have, personal or otherwise. I hereby release all parties, including agents, from any claims,
causes of action, or liability from damages that may or could result from furnishing such information to the company or as a result of information obtained through a background investigation or drug screen.
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