New Industries Job Application Form

Personal Information
Full Name

First NameMiddle NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
If you are not a U.S. Citizen, have you the legal right to work in the U.S.?
Do you have a license to drive in the U.S.?
Emergency Contact:

First NameLast NameRelationshipPhone No.

Education

Please note highest grade completed, degree if applicable, name of school, and date of completion:
Highest Grade Completed:
Degree Earned (if applicable):
School Name:
Date of Completion:

MonthDayYear
Date

Service In United States Armed Forces
Branch/Organization
Date Entered:

MonthDayYear
Date
Date Discharged:

MonthDayYear
Date
Highest Rank / Rating
Specialized Training
Branch/Organization

Employment History

List last four employers, starting with the most recent.
Employment #1
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Company Name:
Supervisor:
Reason for Leaving:
Position / Duties:
Starting Salary:
Salary
Final Salary:
Salary

Employment #2
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Company Name:
Position / Duties:
Supervisor:
Reason for Leaving:
Starting Salary:
Salary
Final Salary:
Salary

Employment #3
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Company Name:
Position / Duties:
Supervisor:
Reason for Leaving:
Starting Salary:
Salary
Final Salary:
Salary

Employment #4
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Company Name:
Position / Duties:
Supervisor:
Reason for Leaving:
Starting Salary:
Salary
Final Salary:
Salary

References

Give the names of three persons NOT RELATED TO YOU, whom you have known at least one year.
Reference #1
Reference Name:

First NameLast Name
Reference Phone Number:

Area CodePhone Number
Reference Business Name:
Business Name
Reference Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference #2
Reference Name:

First NameLast Name
Reference Phone Number:

Area CodePhone Number
Reference Business Name:
Business Name
Reference Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference #3
Reference Name:

First NameLast Name
Reference Phone Number:

Area CodePhone Number
Reference Business Name:
Business Name
Reference Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referral
Were you referred to this company by anyone?
Relatives
Do you have any relatives employed by this company?
If so, who?
Referral Name

Acknowledgments
I AUTHORIZE AND REQUEST EACH EMPLOYER, PERSON, FIRM, OR CORPORATION TO RELEASE ALL INFORMATION THAT MAY BE SOUGHT CONCERNING ME OR MY WORK HABITS, CHARACTER, SKILL, OR ACTION IN ANY TRANSACTION.
I acknowledge:
I UNDERSTAND THAT 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 PREVIOUS NOTICE.
I acknowledge:

Notice to Applicants / Employees Regarding Consumer Reports
Consumer report and/or an investigative consumer report including information concerning your character, employment history, general reputation, personal characteristics, police record, education, qualifications, motor vehicle record, mode of living and/or credit and indebtedness may be obtained in connection with your application for and/or continued employment with the company. A consumer report and/or investigative report may be obtained at any time during the application process and during your employment with the Company. A consumer report containing injury and illness records and medical information may be obtained after a tentative offer of employment has been made. Upon timely written request of the Personnel Department of the Company and within 5 days of the request, the name, address and phone number of the reporting agency and the nature of scope of the consumer report will be disclosed to you.

Before an adverse action is taken, based in whole or in part of the information contained in the consumer report, you will be provided a copy of the report, the name, address and telephone number of the reporting agency, a summary of your rights under the Fair Credit Reporting Act as well as additional information on your rights under the law.
I have read the “Notice to Applicants/Employees Regarding Consumer Reports” and hereby authorize the Company to obtain consumer reports and/or investigative consumer reports as described. I understand that I have the right to make a written request within a reasonable amount of time to receive additional detailed information about the nature and scope of any investigative report or other consumer reports that are made, including the name, address and telephone number of the consumer reporting agency.

I hereby authorize any present or former employer, consumer reporting agencies, educational institutions, criminal justice agencies, department of motor vehicles, public agency, financial institutions or any other person or agency having knowledge of me to submit information or opinions about myself, including data received from other sources in order that my employment qualifications may be evaluated. I hold said persons and/or organizations harmless and without liability for statements or opinions made regarding my character, experience or qualifications.

I agree and consent, as a condition of employment or continued employment, to submit to a urinalysis (drug) test/screen to be paid for by the Agency. I further agree to the search or examination of any personal property I may have on myself while on Company premises or while conducting its business elsewhere. I certify that the answers given by me on this application are true and correct and complete. I agree that any misstatement or pertinent omission made by me in this application may be cause for my rejection or if hired may subsequently subject me to dismissal. In the event of employment, I will comply with all company rules, regulations and directives as may be established or given from time to time. I understand that the company does not offer contracts of employment. I also understand that nothing contained in this application form or any other company document or statement is intended to create a contract of employment nor does it create a contract between the company and me for either employment or the provisions of any compensation or benefits. I understand that if employed I have the right to terminate my employment at any time, for any reason or no reason and likewise the company has the same “Employment At Will” right.
BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD, AND CONSENT TO ALL OF THE PRIOR STATMENTS. I ALSO AGREE THAT ALL INFORMATION SUBMITTED WITHIN THIS APPLICATION IS ACCURATE TO THE BEST OF MY ABILITY.
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Job Application

Personal Information

Employment Desired

Education

Service In United States Armed Forces

Employment History

Employment #1

Employment #2

Employment #3

Employment #4

References

Reference #1

Reference #2

Reference #3

Referral

Relatives

Acknowledgments

Notice to Applicants / Employees Regarding Consumer Reports