Application for Employment

Driver's License

License Number

State

Class Endorsements
Living Locations

List your address information for the Past Three Years
Current Address

Street Address

Street Address Line 2

City State

Zip Code
Former Address

Street Address

Street Address Line 2

City State

Zip Code
Former Address

Street Address

Street Address Line 2

City State

Zip Code
Education
High School

Name of High School

Street Address

City State

Zip Code
Did You Graduate?
If you answered No, did you obtain a GED?
College

College Name

Street Address

City State

Zip Code
Did you Graduate?
Trade, Business, Military, or Technical School

Entity Name

Street Address

City State

Zip Code
Did you graduate
What skills or training do you have which will be of special benefit for this job?

Employment History

Give a complete record of all employment, including military, and reasons for periods of unemployment during the past ten (10) years. If you have been self-employed, list up to five (5) of your major clients. List employers in reverse order starting with the most recent. Please note that regulated / CDL applicants who will drive a regulated vehicle shall provide ten (10) years information on those employers for whom the applicant operated such vehicle.
Current Employment

Company Name

Street Address

City State

Zip Code
Contact Person
Full Name
Phone Number

Area Code Phone Number
Dates Employed From - To
(i.e. mm/dd/yy - mm/dd/yy)
Salary: Beginning of employment to current salary
(i.e. $0,000 per month - $0,000)
Position Held
Check Reason for Leaving

Resigned Discharged Layoff Other
Explain Reason for Leaving
May we contact this employer?

Former Employment

Company Name

Street Address

City State / Province

Postal / Zip Code
Contact Person
Full Name
Phone Number

Area Code Phone Number
Dates Employed From - To
(i.e. mm/dd/yy - mm/dd/yy)
Salary: Beginning of Current Employment
(i.e. $0,000 per month)
Salary: Current
(i.e. $0,000 per month)
Position Held
Check Reason for Leaving

Resigned Discharged Layoff Other
Explain Reason for Leaving
May we contact this former employer?
Former Employment

Company Name

Street Address

City State / Province

Postal / Zip Code
Contact Person
Full Name
Phone Number

Area Code Phone Number
Dates Employed From - To
(i.e. mm/dd/yy - mm/dd/yy)
Salary: Beginning of employment to current salary
(i.e. $0,000 per month - $0,000)
Position Held
Check Reason for Leaving

Resigned Discharged Layoff Other
Explain Reason for Leaving
May we contact this former employer?

Former Employment

Company Name

Street Address

City State / Province

Postal / Zip Code
Contact Person
Full Name
Phone Number

Area Code Phone Number
Dates Employed From - To
(i.e. mm/dd/yy - mm/dd/yy)
Salary: Beginning of employment to current salary
(i.e. $0,000 per month - $0,000)
Position Held
Check Reason for Leaving

Resigned Discharged Layoff Other
Explain Reason for Leaving
May we contact this former employer?
Former Employment

Company Name

Street Address

City State / Province

Postal / Zip Code
Contact Person
Full Name
Phone Number

Area Code Phone Number
Dates Employed From - To
(i.e. mm/dd/yy - mm/dd/yy)
Salary: Beginning of employment to current salary
(i.e. $0,000 per month - $0,000)
Position Held
Check Reason for Leaving

Resigned Discharged Layoff Other
Explain Reason for Leaving
May we contact this former employer?

Personal References

Do NOT include former employers or relatives
Reference

Full Name

Relationship

Occupation Years Known

Phone
Reference

Full Name

Relationship

Occupation Years Known

Phone
Reference

Full Name

Relationship

Occupation Years Known

Phone

Applicant's Statement and Acknowledgement

I, hereby apply for employment with Lucky Family of Companies. The facts set forth in this application for employment are true, complete, and correct. I understand and agree that any misrepresentation, false statement or omission of any fact on this application will be sufficient reason for dismissal or refusal of employment. Furthermore, I understand and agree that should I become employed by one of the Lucky Family of Companies and it is later discovered that information that I have provided on this application or any supplement to or any other corporate records is misrepresented, omitted or falsified, Lucky Family of Companies may immediately terminate my employment upon discovery of such omission, misrepresentation or falsification. I also understand that this application is, nor is not intended to be terminated by either party with or without notice, at any time or for any reason. No one other than an officer of the Company has any authority to enter into any agreement contrary to the foregoing, unless in writing and signed by an officer. I also hereby give permission to contact the above listed employers concerning my prior work experience, excepted as note above.
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