DeLuca Employment Application

First Name*

Last Name*

Middle Initial

Last, First Middle

Date of Birth*

Date

Application Date*

Date

Driver's License Number*

If You Do Not Have A Driver's License Type "NA"

State of Issue

Driver's License Expiration Date

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Phone Number (Archived)*

Your Phone Number*

Monday.com Phone Number

Your Email Address*

example@example.com

Date Available For Work*

Date

Last 4 Digits of SSN*

Desired Salary / Hourly Rate?

Ex: $15/Hour

Position Applying for

Are you a citizen of the United States?

YesNo

Are you authorized to work in the U.S?

YesNo

Have you ever been convicted of a crime including misdemeanors?

YesNo

What name did you go by at the time?

Please explain the crime/misdemeanor:

High School*

Ex: Lake Mills High School

Address or Location of High School

Ex: Lake Mills, Wisconsin

Year you started High School

Year you finished High School

Did you graduate?

YesNo

Company

Phone

Address

Supervisor

Job Title

Responsibilities

Date Started

Date Ended

Reason for Leaving

May we contact your previous employer for reference?

YesNo

How Did You Hear About Us?*

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 or misleading information in my application or interview may result in my release. I hereby understand with my application with DeLuca and Hartman/DeLuca and Tobin, consumer reports will be requested by DeLuca and Hartman/ DeLuca and Tobin. These reports may include, as allowed by law, the following type of information, as applicable: names and dates of previous employers, work experience, education, licensure, etc. I further understand that such reports may contain public record information such as, but not limited to: driving record, workman's compensation claims, judgements, bankruptcy proceedings, evictions, criminal records, etc. from federal, state and other agencies that maintain such records.

If I am hired, I understand that my employer can use this disclosure and authorization to obtain consumer reports throughout my employment or contract period.

I understand at any time during employment or up to two years after termination of employment, this information is available to me with an advanced notice written request.

Any third party agency that requires any employment records/verification from DeLuca and Hartman/DeLuca and Tobin, must have written, signed and dated consent from the employee.

Random Drug Testing: DeLuca and Hartman/DeLuca and Tobin are a drug & alcohol free workplace, and the company will conduct drug and/or alcohol testing under the following circumstances:

Random: Employee may be selected at random for either testing at any interval by DeLuca and Hartman/ DeLuca and Tobin or a representative by their Insurance Company with no cause.

For-Cause Testing: The company may ask any employee to submit to either test at any time if it feels that the employee may be under the influence of drugs or alcohol, including but not limited to the following circumstances: evidence of drugs or alcohol on the employee's person or in the vicinity, unusual conduct on the employee's part that suggest impairment, negative performance patterns, or excessive and unexplained absenteeism or tardiness.

Post-accident Testing: Any employee involved in an on-the job accident of any magnitude. or injury under any circumstances allows DeLuca and Hartman/DeLuca and Tobin the right to test all involved employees for drug and/or alcohol usage.

I have read and understand the Employer's drug and alcohol testing policy.

Signature

DeLuca and Hartman / DeLuca and Tobin - Employment Application

Education

Previous Employment

Disclaimer and Signature