EMPLOYMENT APPLICATION

You Should Answer As Much As Possible
Required Fields To Send This Form Are In Yellow
PERSONAL INFORMATION
Last Name
First Name
Init
Present Street Address
City
 State Zip
Previous Street Address
City
 State Zip
Yes No
Today's Date

Are you a U.S. Citizen?

Social Security No.

Are you an authorized alien working U.S.?
Alien Reg No.

Are you 18 years or older?

Place of Birth
Do you have a home phone?
Phone Number
Is your home phone listed in your name?
Alt Phone
DRIVERS LICENSE INFORMATION
Do you have a Drivers License? Yes No
License Number
Issue Date Exp Date
Endorsements
Restrictions
Have you been convicted of a DUI ? Yes No No. in last 10 years 
Describe:
Have you received any tickets in 5 yrs? Yes No No. in last 5 years
Describe:
(NOTE: A copy of your valid Driver’s License will be required prior to employment.)
TRANSPORTATION INFORMATION
Do you own a vehicle? Yes No What type is your vehicle? Car Van Truck Other
Make
Model
Year
Mileage
Plate No.
Is your vehicle operational? 

Yes No

If not describe:
(NOTE: A copy of valid vehicle insurance will be required prior to employment.)
EMPLOYMENT DESIRED
Position Date Available Salary Desired
Are you employed now? Yes No
If so may we contact your present employer? Yes No
Ever applied to this company before? Yes No Where? When?
EXPERIENCE
How many years have you professionally painted?
What is your previous work experience?
What were your previous responsibilities?
Have you ever been self employed in the painting business? Yes No
Are you currently working for yourself? Yes No
Describe what you did and why you quit?
CONVICTION INFORMATION
Have you been convicted of a felony within the last 5 years? Yes No No.of times
Describe:
 (Note: A conviction record will not necessarily be a bar to employment)
EDUCATION
Name and Location
Years
Graduate
Major Subjects
Grammar School Yes No
High School Yes No
College Yes No

Other School

 Yes No
GENERAL INFORMATION
Subjects of Special Study or Research Work
U.S. Military or Naval Service Rank

Present Membership in National Guard or Reserves

FORMER EMPLOYERS
List below last three employers, starting with last one first.
Month & Year
Name and Address of Employer
Position
Salary
Reason for Leaving

From
To

From
To

From
To

REFERENCES
List the names of three persons not related to you, whom you have known at least one year.
Name Address Phone Yrs Acquainted
PHYSICAL RECORD
Do you have any physical limitations that prohibit you from performing any work? Yes No
Are you afraid of heights? Yes No
Describe Limitations:
What can be done to accommodate your limitation? 
In case of Emergency Notify:
Name
Address
Phone

The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are least 40 but less than 70 years of age.

You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.

POLICIES AND PROCEDURES MANUAL ACKNOWLEDGE
 The information in the company employee manual will increase your knowledge and awareness of the policies and procedures that have been established to ensure the most effective operation of the company. If hired you will be responsible for the performance of your work in the in the safest manner possible and in accordance with: All applicable local, State and federal laws, Safety and Health regulations. Any and all customer Safety Policies and practices. Failure to comply with Company Policies and Procedures and/or OSHA Safety Act will result in termination.

This is to acknowledge that I have reviewed a copy of the Companies Policies and Procedures Manual which I have read and fully understand. I have had the opportunity to ask management questions about parts of the manual that I did not understand fully. I agree, that if hired, I will follow these instructions while employed by this company. I agree, that if hired, I understand that my supervisor must see that these rules are complied with.

If I am injured while at work, I must report it immediately to my supervisor, I understand that my supervisor for proper first aid or medical care before I receive treatment. It is my responsibility to make sure a Company accident report is filled out by my supervisor and signed by me the day of injury.

I AGREE  Yes No

DRUGS AND ALCOHOL
I understand and agree that I may be required to take one or more: Physical Examination(s): Urine test(s) for drugs & alcohol, as a condition of hiring or continued employment. I agree to consent to take such test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising in connection with the use of test(s).

I AGREE  Yes No

I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.”

I AGREE Yes No