| NAME, FIRST: MIDDLE: LAST: |
| POSITION APPLIED FOR: |
| CURRENT ADDRESS: HOW LONG?: |
| PREVIOUS ADDRESS: HOW LONG?: |
| PHONE: SS#: DATE OF BIRTH (opt): |
| DRIVERS LICENSE #: |
| STATE OF ISSUE: OTHER LAST NAMES USED: |
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| EMPLOYMENT EXPERIENCE |
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| 1. MOST RECENT EMPLOYER: |
| STREET ADDRESS: |
| CITY: STATE: ZIP: |
| PHONE: LAST SUPERVISOR'S NAME: |
| MAY WE CONTACT EMPLOYER?: YES NO |
| DATE EMPLOYED - START: END: |
| PREVIOUS DUTIES: |
| REASON FOR LEAVING: |
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| 2. PREVIOUS EMPLOYER: |
| STREET ADDRESS: |
| CITY: STATE: ZIP: |
| PHONE: LAST SUPERVISOR'S NAME: |
| MAY WE CONTACT EMPLOYER?: YES NO |
| DATE EMPLOYED - START: END: |
| PREVIOUS DUTIES: |
| REASON FOR LEAVING: |
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| 3. PREVIOUS EMPLOYER: |
| STREET ADDRESS: |
| CITY: STATE: ZIP: |
| PHONE: LAST SUPERVISOR'S NAME: |
| MAY WE CONTACT EMPLOYER?: YES NO |
| DATE EMPLOYED - START: END: |
| PREVIOUS DUTIES: |
| REASON FOR LEAVING: |
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| EDUCATION & SKILLS Please choose the highest grade completed: |
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PROFESSIONAL REFERENCES Include only individuals familiar with your work ability.
Do not include relatives. |
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| HAVE YOU EVER BEEN CONVICTED OF A FELONY?: YES NO |
| IF YES, PLEASE DESCRIBE (this will not necessarily exclude you from consideration): |
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| CERTIFICATION AND NOTICE |
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This application form is intended for use in evaluating your suitability for employment. It is not an employment contract. Please answer all appropriate questions completely and to the best of you ability. Additional testing of jab related skills may be required prior to employment.
I certify that the information I have provided on this application is complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts may result in rejection of my application or discharge at any time during my employment. I authorize the company or its representatives to investigate all statements contained in this application which may be necessary to arrive at an employment decision. |
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| PLEASE SIGN HERE: DATE: |
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| DISCLOSURE: A CONSUMER REPORT MAY BE PROCURED FOR EMPLOYMENT PURPOSES. |
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In accordance with the Fair Credit Reporting Act, a consumer or investigative consumer report including information about your credit, general reputation, character, or personal characteristics may be obtained. Upon written request, you will be provided with information regarding the nature and scope of the report, should it include information about your general reputation, character, or personal characteristics, and a summary of your rights. I understand if my application for employment is granted, further information may be obtained through subsequent investigations so as to update, renew or extend my employment. |
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| RELEASE AND AUTHORIZATION |
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I voluntarily and knowingly authorize for employment purposes only, any present or past employer or supervisor, university or institution of learning, administrator, law enforcement agency, state agency, federal agency, credit bureau, private business, military branch or the National Personnel Records Center, the Minnesota Bureau of Criminal Apprehension, personal reference, and/or other persons, to give records or information they may have concerning my criminal history, motor vehicle history, earnings history and employment records, credit history, corker's compensation claims (including from the state of MN), general reputation, character, or any other information requested to Employment Screening Services, Inc. and/or its agents or representatives. I voluntarily and knowingly unconditionally release any named or unnamed informant from any and all liability resulting from the furnishing of this information. A photographic or faxed copy of the authorization shall be as valid as the original. In compliance with the 1990 Americans with Disabilities Act, a worker's compensation search may only be requested when a conditional job offer exists. |
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CA and MN APPLICANTS ONLY:
You have the right to receive a copy of your Consumer Credit Report (for CA) or Consumer Report (for MN) should one be requested for employment reasons.
I wish to be furnished with a copy of my consumer report should one be ordered. |
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