Employment Application Form

Applicant Information
Date*

MonthDayYear
Date
Name:*

First NameMiddle NameLast Name
SSN*
Birth Date*

MonthDayYear
Phone Number:*

Area CodePhone Number
E-mail Address:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Applied For*
Are you a citizen of the United States?*
Have you been convicted of a felony?*
How were you referred to us?

Walk-InEmployeeNewspaper AdFacebookTwitterCraigslistOther (please specify)
Others:
Upload Resume:

Upload a File

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Job Skills & Training
Describe your skills:
Training or Certifications:
References

Please list two (2) references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number

Area CodePhone Number
Years Known:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2
Name:*

First NameLast Name
Phone Number

Area CodePhone Number
Years Known:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Education
High School
From

MonthDayYear
Date
To

MonthDayYear
Date
Did you graduate?

YesNo
College
From

MonthDayYear
Date
To

MonthDayYear
Date
Did you graduate?

YesNo
Previous Employment
Employer 1*
Employer 2
Employer 3
Military Service
Branch
Dates Served
From and To
Rank at Discharge
Type Of Discharge
Disclaimer And Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false misleading information in my application or interview may result in my release.
Signature*

Clear

Consumer Authorization
To Whom It May Concern:

I hereby authorize and request any present or former employer, school, police department, financial institution, drug screening facility or other person having personal knowledge about me, to furnish bearer with any and all information, including but not listed criminal, driving, credit history and Global Watch Alert information, in their possession regarding me in connection with an application for employment. I am willing that a photocopy of this authorization be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorization request. I understand this authorization is to be part of the written employment application that I sign.
I have been given a stand-alone, consumer notification that a Consumer Report or Investigation Consumer Report will be requested and used for the purpose of evaluating me for employment, promotion, reassignment, or retention as an employee.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex (optional - use for identification purposes only)
Race (optional - use for criminal history only)
Date of Birth*

MonthDayYear
Date
SSN*
Drivers License Number
DL State Issued
Upload Drivers License

Browse Files

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Print all former names used
List all former addresses for the past 7 years*

Consumer Reports and Investigative Consumer Reports

Disclosure Notice and Authorization
Disclosure:
This form is to notify you that a Consumer Report and/or an Investigative Consumer Report may be obtained as part of a background check for your employment process. A "Consumer Report" is any written, oral, or other communication bearing onreputation, personal characteristics and/or mode of living. An "Investigative Consumer Report" contains information which is obtained through personal interviews with your business associates, family members, friends, neighbors, or other third parties with whom you are acquainted. This information will include inquiries regarding your personal characteristics and/or mode of living.
If any adverse employment decision is made based on the information contained in a consumer report or an investigative consumer report, you will be given a copy of the report as well as a summary of your rights under the Fair Credit Reporting Act.
Authorization:
By my signature below, I authorize PCG Screening Services, LLC to receive & release information in connection with my application for employment. I authorize all law enforcement agencies and courts to release all written and verbal information about me to include criminal history record information and driving license history record information. I further authorize the performance of, the procurement of and the release of consumer reports and/or investigative consumer reports which may include information about my employment and/or education. I further understand that any and all information contained in my job application may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports and I confirm that all such information is true and correct. This authorization is good for 180 days from date of signature and if hired, will remain in effect for periodic background checks for the duration of my employment with this company. Facsimile and electronic signature, when used, shall be deemed legal, valid and binding upon the signing party to this agreement. I understand that I am not required to use facsimile or electronic signatures: at my option, I may elect to sign on paper and mail this form.
Applicant's Name*

First NameLast Name
Maiden Name or Other Names Used
Date Of Birth*

MonthDayYear
Date
Social Security Number
DRIVERS LICENSE#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Signature*

Clear
"_____California, Minnesota, and Oklahoma residents only: Please check here if you would like a copy of your report sent directly to the address listed above."
Type a question
Should be Empty: