Secure Server Employment Application Form

Personal Information
(* required fields)
 

*Name   
*Address   
*City     
*State   
*Zip   
*Home Phone   
Work Phone   
Cell Phone   
*Email   
*Best Way to Contact Me   
Referred by   
Social Security Number   

Employment Desired
 
 
Position Desired   
Date you can start   
Salary requirements   
*Full Time or Part Time     
If Part Time - How many   
hours a week are you seeking?   
 
*Are you presently employed?     

*May we contact your   
present employer?   

 
*Have you previously applied   
or been employed by us?
   
 
Why are you seeking a   
change in employment?   
*Have you ever been   
terminated from employment?
  
 
If so, please explain...   
*Have you ever been   
convicted of a felony?
  
 
If so, please explain...   
*Are you able to perform the   
essential functions of the job   
you are applying for?
  
 

Current Employer
 
 
Date from   
Name and Address   
of Employer   
Salary   
Supervisor  
Position   
Job Title / Duties   
Reason for leaving   

Previous Employer 1

 
 
Date from   
Date to   
Name and Address   
of Employer   
Supervisor   
Salary   
Position   
Job Title / Duties   
Reason for leaving   


Previous Employer 2
 

 
Date from   
Date to   
Name and Address   
of Employer   
Supervisor   
Salary   
Position   
Job Title / Duties   
Reason for leaving   


Previous Employer 3
 

 
Date from   
Date to   
Name and Address   
of Employer   
Supervisor   
Salary   
Position   
Job Title / Duties   
Reason for leaving   

Business References
(please provide contact information
below for 4 business references who have knowledge of your abilities)

 
 

Reference 1
 
 
Name, Address & Telephone   
Job Title and Company   
Years Known   

Reference 2
 
 
Name, Address & Telephone   
Job Title and Company   
Years Known   

Reference 3
 
 
Name, Address & Telephone   
Job Title and Company   
Years Known   

Reference 4
 
 
Name, Address & Telephone   
Job Title and Company   
Years Known   

Education History
(include name and address of school, major
or courses, dates, grade average, degree)

 
 
High School   
College   
Trade, Business,   
Correspondence, or other School   
Indicate any academic achievements,   special training or skills and aptitudes   which qualify you for a position with us   
Please describe your career objectives   
   

Additional Information
 
 

Any additional information   
you wish to provide   



Equal Opportunity Employer

We are an equal opportunity employer and do not discriminate in recruiting, hiring, training, promoting or other employment practices, on the basis of race, color, religion, sex, marital status, age, national origin, or veteran or handicap status. No question in this application is intended to obtain information to be used for such discrimination.

By submitting this form...

I understand that I must be a U.S. Citizen or a properly authorized alien to
   qualify for employment. 

I understand that employment is for no definite period of  time and it may be
   terminated at any time by either the company or me.

I agree to abide by all policies and rules and that all company information is
   strictly confidential.

I agree that employment is contingent upon reference checks and authorize
   such contacts. I understand that employment is contingent upon the
   results of a drug test.

I understand that an investigative consumer credit report may be requested
   prior to employment and at any time during employment and that I may request
   the results of the report.

I understand that a surety bond may be required and if not bondable, I will not be
   offered employment.

I certify that all statements by me on this application are true and complete and
   if not, are cause for disqualification or termination.  This application is active for
   60 days unless  renewed by applicant.

Your information is submitted via our Secure Server
       using the latest in SSL data encryption technology.

 

Revised: June 30, 2019