If you have worked in any of your previous positions under another name, please give that name(s) below.
(For reference checking purposes)
Name: @Company:
Name: @Company:
Are you presently employed?
Yes No
May we contact your employer?
Yes No
Please list all periods of time since high school or college during which you were not employed.
AUTHORIZATION AND UNDERSTANDING:
Date Signature
REFERENCES
Phone Number
I agree that, if I am employed, I will abide by all the rules and regulations of the Company. I understand that the taking of drug
and alcohol tests, when given pursuant to company policy, are a condition of continued employment and refusal to take such tests
when asked will be grounds for my immediate termination. I further understand that nobody in the Company is authorized to
enter into any written or verbal employment contracts with me for any definite period of time without the express written consent
of the President of the Company.
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 herby 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. 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 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 and Federal law, but not Federal civil rights statutes
containing a separate limitations period, must be brought within 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, 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.
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