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EMPLOYMENT EXPERIENCE (List current or most recent job first)
Employer
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Job Title
Supervisor
Reason For Leaving
Date(From)
MM
DD
YYYY
Date(To)
MM
DD
YYYY
Starting
Final
Work Performed
EMPLOYMENT EXPERIENCE (List current or most recent job first)
Employer
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Reason For Leaving
Date(From)
MM
DD
YYYY
Date(To)
MM
DD
YYYY
Starting
Final
Work Performed
EMPLOYMENT EXPERIENCE (List current or most recent job first)
Employer
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Reason For Leaving
Date(From)
MM
DD
YYYY
Date(To)
MM
DD
YYYY
Starting
Final
Work Performed
List Any other positions held on a separate sheet

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EDUCATION DETAILS

Education	Name/Location	Years Completed	Diploma/Degrees	Courses of Study
Elementary
High School
College
Graduate
Vocational/Training

REFERENCES (Do not include relatives or former employers)
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Years Acquainted
REFERENCES (Do not include relatives or former employers)
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Years Acquainted
REFERENCES (Do not include relatives or former employers)
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Years Acquainted
MILITARY SERVICE RECORD
Have you had any experience in the Armed Forces of the United States or in a State National Guard?
- Yes
- No
If yes, what branch?
Rank at Discharge
Date of Discharge
MM
DD
YYYY
Are you in the reserves?
- Yes
- No
If yes, date obligation ends
Special/technical training
ADDITIONAL INFORMATION
Have you been convicted of a crime?
If so, where, when and nature of offense
Do you have a valid driver's license?
- Yes
- No
License No
State
List professional trade, business or civic activities and offices held excluding groups the name or character of which indicate race, color, religion, sex, national origin, handicap, marital or veteran status, height, weight or age
State any additional information that you feel may be helpful to us in considering your application.
Name, address, and telephone number of the person to be notified in the event of accident or emergency
AUTHORIZATION AND UNDERSTANDING:
Upon the signing of this application, I represent that all of the information now or hereafter given by me in support of my application is true and complete. I authorize you to verify any of the information concerning my background, including but not limited to, my employment, driving record, education, criminal history, or medical history (post-offer only), with the appropriate individuals, companies, institutions or agencies, and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I also authorize you to release any information requested by any of my prospective or subsequent employers without any obligation to give me written notice of such disclosure. I hereby release you and them from any liability whatsoever as a result of any such inquiries and disclosures and this release from liability does not waive or prohibit an individual from filing a charge of discrimination under the laws enforced by the EEOC. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment.

I agree that either party may terminate the employment relationship, with or without cause, at any time, and I further agree that this arrangement may only be altered in writing directed to me personally and signed by the president of the firm. m. I agree that I shall be bound by the other rules, policies, regulations and terms and conditions of employment of the firm as they are from time to time changed, and no additional obligations can be imposed on the firm except those which have been acknowledged in writing, by the president or his designated representatives. I hereby authorize the firm to deduct from each and every period of my pay any amounts necessary to offset any damages caused by me or the value of property or money entrusted to me by, or owed by me to, the firm during the course of my employment.

irm during the course of my employment. I agree that any action or suit against the firm, its agents or employees, arising out of my employment or termination of employment, including, but not limited to, claims arising under State, but not Federal, civil rights statutes, must be brought within 180 days of the event giving rise to the claims or be forever barred unless the applicable statute of limitations period is shorter than 180 days in which case I will continue to be bound by that shorter limitations period. I waive any limitation periods to the contrary. I further agree that if I should bring any non-statutory action or claim arising out of my employment against the firm, in which the firm prevails, I will pay to the firm any and all such costs incurred by the firm in defense of said claims or actions, including attorney fees. I further agree that my employment is conditional until such time as the results of my post-offer physical (if such physical is required) are known.
Date
MM
DD
YYYY
Signature

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FOR INTERVIEWER'S USE
Interviewed by
Date
MM
DD
YYYY
Comments
FOR INTERVIEWER'S USE
Interviewed by
Date
MM
DD
YYYY
Comments
FOR INTERVIEWER'S USE
Interviewed by
Date
MM
DD
YYYY
Comments
HIRED
HIRED:
- Yes
- No
Starting Date
MM
DD
YYYY
Department
Job Title
Comments
APPROVED
Untitled
Name
First Last
Title
Date
MM
DD
YYYY
A Summary of Your Rights Under the Fair Credit Reporting Act Issued by the Federal Trade Commission The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every "consumer reporting agency" (CRA). Most CRAs are credit bureaus that gather and sell information about you -- such as if you pay your bills on time or have filed bankruptcy -- to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. 1681-1681u, at the Federal Trade Commission's web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights. • You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you -- such as denying an application for credit, insurance, or employment -- must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report. • You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars. • You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise national CRAs -- to which it has provided the data -- of any error.) The CRA must give you a written report of the investigation, and a copy of your report if the investigation results in any change. If the CRA's investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change. • Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source. • You can dispute inaccurate items with the source of the information. If you tell anyone -- such as a creditor who reports to a CRA -- that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you've notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error. • Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies. • Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. • Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission. • You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely. • You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court. The FCRA gives several different federal agencies authority to enforce the FCRA: FOR QUESTIONS OR CONCERNS REGARDING: PLEASE CONTACT CRAs, creditors and others not listed below Federal Trade Commission Consumer Response Center - FCRA Washington, DC 20580 202-326-3761 National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name) Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 800-613-6743 Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 202-452-3693 Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name) Office of Thrift Supervision Consumer Programs Washington, DC 20552 800-842-6929 Federal credit unions (words "Federal Credit Union" appear in institution's name) National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 703-518-6360 State-chartered banks that are not members of the Federal Reserve System Federal Deposit Insurance Corporation Division of Compliance & Consumer Affairs Washington, DC 20429 800-934-FDIC Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Department of Transportation Office of Financial Management Washington, DC 20590 202-366-1306 Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC 20250 202-720-7051

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