Relay Express: Employee Application

PERSONAL BACKGROUND

Date (MM/DD/YY):

Name:

Present Address

Address:

City:

State:

Zip Code:

Permanent Address

Address:

City:

State:

Zip Code:

Phone:

Email:

Social Security No.:

Position Applying for:

What date can you start?

Salary Desired:

Specify Hours:

Ever applied to
this company before?

Where?

When?

Are you willing to work overtime?

Are you presently employed?

If so, can we inquire of
your present employer?

Referred by:

LOCATION

Choose an office location
to which you are applying:

If driving is a requirement of the job for which you are applying, do you have a valid driver's license?

Yes
No

If you are a minor, can you produce the work certificate necessary to obtain employment?

Are you able, at the time of employment, to submit verification of your legal right to work in the U.S.? (Verification and completion of Form I-9 must be submitted no later than three business days after date of hire.)

Have you ever been convicted ofa felony which is substantially related to the functions or qualifications of the positions(s) for which you are applying? Note: This question does not apply to convictions which have been expunged or sealed. (A conviction record will not necessarilly be a bar to employment.)

If so, please describe fully the criminal conviction(s), listing the nature of the offense(s) and your rehabilitation since the conviction(s).

EDUCATION

High School

Name and Location of School:

Years Attended:

Did You Graduate?

College

Name and Location of School:

Years Attended:

Did You Graduate?

Trade or Tech School

Name and Location of School:

Years Attended:

Did You Graduate?

Specialized Technical Skills (i.e., computer programming/language, software, equipment operation, special tools or machines)

WORK EXPERIENCE

Please list below your last three employers, starting with your present or last place of employment.
You may include any verifiable work performed on a volunteer basis, internship or military service.

Job 1

Dates (MM/YY):

From:   To:

Name, Address and Phone Number of Employer

Salary:

Position:

Reason for Leaving:

Job 2

Dates (MM/YY):

From:   To:

Name, Address and Phone Number of Employer

Salary:

Position:

Reason for Leaving:

Job 3

Dates (MM/YY):

From:   To:

Name, Address and Phone Number of Employer

Salary:

Position:

Reason for Leaving:

Which of these jobs did
you like the best?

What did you like about this job?

REFERENCES

List three persons not related to you, whon you have known at least one year.

Reference 1

Name:

Address:

Phone Number:

Occupation:

Reference 2

Name:

Address:

Phone Number:

Occupation:

Reference 3

Name:

Address:

Phone Number:

Occupation:

APPLICANT'S STATEMENT

By submitting this application, I understand that if hired by the company, I will be an employee at will. This means my employment with the company may be terminated at any time at the option of the company or me. I also understand that neither this application nor any communication by a managment representative is intended to create or does in fact create a contract of employment.

I agree to conform to the rules and regulations of the company, and I understand that the company has complete discretion to modify such rules and regulations at any time, except that it will not modify its policy of employment at will.

The above information is complete and true to the best of my knowledge. I understand that any misrepresentation or omission on my part of the facts in this application may result in immediate dismissal.

I hereby authorize you to conduct any investigation necessary concerning any part of my background related to the position I am seeking. I release all parties from any liability in connection with the provision and use of such information.