Progressive Services Employment Application

1064 West Highway 50 Clermont, FL 34711 Phone: 352-394-0493

Email: astalma@progressiveservices.com

Employment Application/Questionnaire

Personal Information

Name:

Last Name, First Name

Middle Initial

Date of Birth:

Date

Social Security #:

Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you 18 years or older?

YesNo

Email Address:

example@example.com

Phone Number

Desired Employment

Position:

Date you can start:

Date

Salary desired:

Are you currently employed?

YesNo

May we contact your present employer?

Have you ever applied to this company before?

YesNo

When and Where?

Have you ever worked for this company before?

YesNo

When and Where?

Reason for leaving:

Name of last supervisor at Progressive Services:

How were you referred to this company?

Education

	Name and Location of School	Subject Studied	Number of Years Attended	Did You Graduate?
Grammar School
High School
College
Other Schooling

Special Training or Skills:

Employment History

List your last three employers, starting with the most recent first.

Present or Most Recent Employer:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor and Title:

Starting Position:

Ending Position:

Phone Number

Area CodePhone Number

Starting Date

Date

Ending Date:

Date

May we contact this employer?

YesNo

Starting Salary & Frequency:

Ending Salary & Frequency:

Description of Work:

Reason for Leaving:

Former Employer:

Address

Street Address Line 2

CityState

Zip

Supervisor and Title

Starting Position:

Ending Position:

Phone Number

Area CodePhone Number

Starting Date:

Date

Ending Date:

Date

May we contact this employer?

YesNo

Starting Salary & Frequency:

Ending Salary & Frequency:

Description of Work:

Reason for Leaving:

Former Employer:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor and Title:

Starting Position:

Ending Position:

Phone Number

Area CodePhone Number

Starting Date:

Date

Ending Date:

Date

May we contact this employer?

YesNo

Starting Salary & Frequency:

Ending Salary & Frequency:

Description of Work:

Reason for Leaving:

References

Below list the names of three (3) persons, not related to you, who you have known for at least one (1) year.

1. Name

First NameLast Name

Address and Phone Number

Occupation

Years Known

2. Name

First NameLast Name

Address and Phone Number

Occupation

Years Known

3. Name

First NameLast Name

Address and Phone Number

Occupation

Years Known

Criminal History

Have you been convicted of a felony within the last five (5) years?

YesNo

If yes, please explain:

Notice to Applicants

We Comply with the Americans with Disabilities Act of 1990. During the interview process, you may be asked questions concerning your ability to perform job-related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical questionnaire and/or undergo a medical examination. If required, all new employees in the same job category will be subject to the same medical questionnaire and/or undergo a medical examination, and all information will be kept confidential in separate files.

We are an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, sex, religion, national origin, handicap, or marital status. We assure you that your opportunity for employment with this employer depends solely upon your qualifications.

Please Read and Sign the Statement Below

I understand that in accordance with Florida Statute 443.131 (3)(A2), if hired, I will be placed on a 90-day introductory period. I further understand that if I am terminated for unsatisfactory performance within the 90 day introductory period, the employer may seek to contest any unemployment benefits I might attempt to obtain as a result of my termination.

Initials

I understand and agree that all policies, procedures, and the employee handbook may be modified, amended, or deleted by the company with or without notice to me of such amendment, modification, or deletion. The policies and procedures are not intended to be a contract of employment nor do they give me a right of continued employment. I understand that my employment may be terminated at my option or the option of the employer at any time. I also understand that there are no other arrangements, agreements, or exception to this statement, unless they are in writing and signed by the President of Progressive Services.

Initials

I understand that I will be required to undertake urine screening for drugs or alcohol use as part of Progressive Services' pre-employment process. In addition, all employees are subject to blood and/or urine screening for drug use.

Initials

I certify that all information given on my employment application, any resume that I submit to the company, and any related papers and answers given during the initial interview are true, complete, and correct. I understand that the employer will make a thorough investigation of my work and personal history. I authorize that transmittal of any such information requested by the company during the course of the investigation. I understand that falsification or omission of information given by me or others during the course of the investigation, any derogatory information discovered as a result of this investigation, or any information provided to Progressive Services during the course of any such investigation, may result in my release from Progressive Services.

Initials

Date

Signature

Job Site:

Full Name:

SS#:

Any other name(s) used in the past or present:

Address:

City:

State:

Zip:

Driver's License #:

Only for motor vehicle report

State

Date of Birth:

Date

In applying for employment with Progressive Services, LLC. (“Company”), I hereby authorize the Company, or any designated agent(s) working on the Company’s behalf, including but not limited to reporting agencies or professional investors to obtain and review those reports checked off below as well as following up on information presented in the reports. The Company or its agents may also request these reports and information during the course of any employment as a condition of continued employment. My consent extends to any possible investigations performed during the course of the employment, including those related to complaints of discrimination, harassment, theft or other conduct.

It is my understanding the information being obtained will not be used in violation of any federal or state equal opportunity law or regulation, and that, before any adverse action is taken, based on upon review of such consumer credit report, I will be provided with a copy of said report as well as a summary of consumer’s rights.

I understand the nature and scope of said inquiries may include, but are not limited to, verification, inspection and/or reporting of any lawfully available records or information pertaining to work history; social security number, education; workers’ compensation claims, criminal and civil court related actions; driving history (including traffic related offenses); personal financial status (including consumer credit reports); and any other information available from any public or otherwise documented record. It may also include inquires regarding any past or present business, professional or personal activities.

I hereby state that to the best of my knowledge all information I have provided to the Company, and any reporting agency, in any form, is true and accurate. I understand that any misrepresentation made to the Company or reporting agency by me will exclude me from further consideration as a candidate for employment or advancement, and may result in termination of my employment with the Company if I am hired or advanced by the Company before such misrepresentation is discovered. I fully understand this authorization, waiver and release of liability is not an offer or a contract for employment by the Company. It is also understood that the Company operates under an “at-will” employment policy and that this authorization and release does not alter or affect this policy in any manner.

Authorization to Obtain Criminal Information

I hereby authorize the Company, reporting agency or investigator to request, obtain and examine any and all records that may relate to my arrest, conviction and/or imprisonment at any time prior to this date, to the extent permitted by law.

Initials

Authorization to Obtain Background Report

I hereby authorize the Company, reporting agency or investigator to request an employment background report.

Initials

Authorization to Obtain Motor Vehicle Records

I hereby authorize the Company, reporting agency or investigator to acquire and examine a copy of my current Motor Vehicle Record.

Initials

Authorization to Obtain Past Workers Compensation History and Medical Information

I hereby authorize the Company, reporting agency, investigator or physician to acquire and examine, after a conditioned job offer, information about past workers compensation claims and medical history.

Initials

Authorization to Conduct Post-Hire Investigation

I hereby authorize the Company, reporting agency or investigator to obtain reports or conduct investigations as a condition of continued employment.

Initials

Signature:

Date

Witness:

Date:

Date

For information on your rights under the Fair Credit Reporting Act, please go to www.ftc.gov.

Note: A copy of this form shall be valid as the original.

PRE-EMPLOYMENT INFORMATION DISCLOSURE NOTICE AND ACKNOWLEDGEMENT