Application

APPLICANT INSTRUCTIONS If you need help to fill out this application form or for any phase of the employment process, please call 501-843-3585 and every effort will be made to accommodate your needs in a reasonable amount of time.
TODAY'S DATE

MonthDayYear
Date
FULL NAME
SOCIAL SECURITY NUMBER
HOME PHONE
WORK PHONE
CURRENT STREET ADDRESS
CITY
STATE
ZIP
PREVIOUS STREET ADDRESS
CITY
STATE
ZIP
This application form is intended for use in evaluating your qualifications for employment . This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are qrounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without diserimination because of sex, marital status, race, age, creed, national origin or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After- an offer of employment and prior to reporting to work, you are required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.
FOR WHICH POSITION ARE YOU APPLYING?
HAVE YOU PREVIOUSLY WORKED AT DREAMLINE?

YESNO
IF SO, WHEN?
EDUCATION - Please enter highest grade completed.
HIGH SCHOOL
CITY/STATE
GRADUATE?

YESNO
COLLEGE
CITY/STATE
GRADUATE?

YESNO
LIST ANY OTHER NAMES OR SOCIAL SECURITY NUMBERS YOU HAVE USED
HAVE YOU BEEN CONVICTED OF A FELONY AND/OR SERVED TIME IN THE PAST SEVEN YEARS?

YESNO
IF SO, PLEASE DESCRIBE BELOW. (in acccordance with company policy, this information will be reviewed for job relatedness and time since last conviction.)
LIST STATES AND COUNTIES OF RESIDENCE FOR THE PAST 7 YEARS
JOB-RELATED SKILLS
HAVE YOU HAD ANY MOVING TRAFFIC VIOLATIONS IN THE LAST 3 YEARS?

YESNO
PLEASE LIST ANY OTHER SKILLS, LICENSES OR SERTIFICATES THAT MAY BE JOB RELATED OR THAT YOU FEEL WOULD BE OF VALUE TO THIS JOB OR COMPANY.
HAVE YOU BEEN GIVEN A JOB DESCRIPTION OR HAD THE REQUIREMENTS OF THE JOB EXPLAINED TO YOU?

YESNO
DO YOU UNDERSTAND THESE REQUIREMENTS?

YESNO
CAN YOU PERFORM THE REQUIREMENTS OF THIS JOB WITH OR WITHOUT REASONABLE ACCOMODATION?

YESNO
EMPLOYMENT REFERENCES - Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical.
MOST RECENT EMPLOYER
ARE YOU CURRENTLY WORKING FOR THIS EMPLOYER?

YESNO
IF YES, MAY WE CONTACT THEM?

YESNO
Company Name
CITY
STATE
PHONE NUMBER
DATE EMPLOYED FROM

MonthDayYear
DATE EMPLOYED TO

MonthDayYear
JOB TITLE
SUPERVISOR NAME
DUTIES
SALARY
REASON FOR LEAVING
SECOND MOST RECENT EMPLOYER
COMPANY NAME
CITY
STATE
PHONE NUMBER
DATE EMPLOYED FROM

MonthDayYear
DATE EMPLOYED TO

MonthDayYear
JOB TITLE
SUPERVISOR NAME
DUTIES
SALARY
REASON FOR LEAVING
THIRD MOST RECENT EMPLOYER
COMPANY NAME
CITY
STATE
PHONE NUMBER
DATE EMPLOYED FROM

MonthDayYear
DATE EMPLOYED TO

MonthDayYear
JOB TITLE
SUPERVISOR NAME
DUTIES
SALARY
REASON FOR LEAVING
REFERENCES
NAME
PHONE NUMBER
YEARS KNOWN
RELATIONSHIP
NAME
PHONE NUMBER
YEARS KNOWN
RELATIONSHIP
COMMENTS
Type a question
CERTIFICATION AND RELEASE I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this, application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reports bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

Iunderstandifmyemployment hired, that, terminated at any. time for any reason.

I further understand that this application will only be effective for thirty (30 days and, after that time I will not be considered for employment unless I have submitted another application.
SIGN BY TYPING YOUR FULL NAME
DATE

MonthDayYear
Date
Should be Empty:

JOB-RELATED SKILLS

MOST RECENT EMPLOYER

SECOND MOST RECENT EMPLOYER

THIRD MOST RECENT EMPLOYER

REFERENCES

COMMENTS