Personal Information Name Email Present address City State Zip code Permanent address City State Zip code Phone number Secondary phone number Referred by Clean driving record?YesNo Employment Desired PositionTechnicianSalesOffice StaffIT SupportJourneyman ElectricianOther If applying for Technician, can you lift 75lbs?YesNo Date you can start Salary desired LocationMissouriTexas City Shifts AvailableMonday – FridayTuesday – Saturday Desired statusFull-TimePart-Time Are you employed now?YesNo If so, may we inquire of your present employer?YesNo Have you ever applied to this company before?YesNo Where When Education History Name & Location of School Years Attended Did you Graduate Subjects Studied High school YesNo College YesNo Trade, business, or correspondence school YesNo General Information Subject of special study/research work Special training Special skills U.S. Military or Naval Service Rank Do you have any physical condition or handicap (physical/mental) that may limit your ability to perform the job for which you are applying?YesNo If yes, what accommodation could we consider to make your employment possible in the job you are seeking? Former Employers (List your last four employers, starting with last one first.) DATE (MONTH & YEAR) NAME & ADDRESS OF EMPLOYER SALARY & POSITION REASON FOR LEAVING References (Give the names of three persons not related to you, whom you have known at least one year.) NAME ADDRESS BUSINESS YEARS KNOWN Certification and Understanding APPLICANT PLEASE READ CAREFULLY I agree to comply with all rules of this company, I hereby affirm that all the foregoing statements are true and correct and that I have not knowingly withheld any fact that would, if disclosed, affect my application unfavorably. I hereby authorize the company to conduct any investigation it deems necessary with respect to information set forth on this application. I also hereby authorize this company to release such information together with their opinions on these matters without any liability for any damages whatsoever caused either directly or indirectly by giving or receiving such information or opinions. I authorize any former employer, present employer, schools, colleges, and universities utility companies, credit, finance bureau/offices, personal references, and/or other persons to give any information they may have concerning my character, health, credit, and employment record. I hereby unconditionally release any names informant form any and all liability resulting from the furnishing of this information. I understand that nothing herein or otherwise shall be deemed to create any contract of employment between the company and me and that my employment may be terminated by the company or me at any time without advances notice one to the other. In making this application for employment, I also understand than an investigative consumer report may be made whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics, and mode of living. I understand that I have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigative consumer report. Date Signature