Bellview Pump Sales and Service Job Application Form

Full Name*

First NameMiddle InitialLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Phone Number*

Area CodePhone Number

Available start date:*

MonthDayYear

Do you have a valid driver's license?

YesNo

Are you authorized to work and remain in the United States?

YesNo

Were you ever discharged or forced to resign from any position?

YesNo

If Yes, Explain:

Have you ever been convicted of any violation of the law? (Exclude traffic violations) A conviction will not necessarily disqualify an applicant from the position sought.

YesNo

If Yes, Explain:

Are you a High School Graduate?

YesNo

High School Equivalency?

YesNo

Are you presently attending school?

YesNo

Type of Education

Field of Study

Name of Institution

Did you Graduate?

YesNo

Type

Date Issued

Expiration Date

MonthDayYear

List Background and Years of Experience:

Equipment Operated:

Name of Employer:

Job Title:

Phone Number

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Supervisor:

Ending Salary Per Month:

Date started

MonthDayYear

Date ended

MonthDayYear

Reason for Leaving:

Description of Duties:

Do you have additional employers to enter?

YesNo

Name of Employer:

Job Title:

Phone Number

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Supervisor:

Ending Salary Per Month:

Date started

MonthDayYear

Date ended

MonthDayYear

Reason for Leaving:

Description of Duties:

Inquiry may be made of your current and former employers/schools you attended.

May we contact your present employer?

YesNo

May we contact your former employers?

YesNo

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Business or Occupation

Phone Number

Area CodePhone Number

APPLICANT’S STATEMENT AND AUTHORITY TO RELEASE INFORMATION

(Required for ALL Positions)

I understand that this employment application and any other documents are not contracts of employment, and any person hired may be terminated by the employer at any time for any reason. I understand that any oral or written statements to the contrary are expressly disavowed and should not be relied upon by a prospective or existing employee. I understand that Bellview Pump Sales &Service may modify, change, or revoke any of its employment policies, pay practices, and benefits without my agreement. I hereby state that all answers on this application are true and understand that falsifying this information can lead to termination if hired. I UNDERSTAND THAT IN ACCORDANCE WITH POLICY, FINAL CANDIDATES ARE SUBJECT TO AN ALCOHOL / DRUG TEST AS A CONDITION OF EMPLOYMENT.

I hereby authorize any and all persons, companies, or agencies to release any and all background information, of a confidential or privileged nature, including criminal history, relevant to this application and any pertinent information they may have to the hiring authorities of Bellview Pump Sales & Sevice. I release all such parties from all liability of every kind as the result of furnishing the same to Bellview Pump Sales & Service. This information is to be used to assist the Company in determining my qualifications and fitness for the position I am seeking. I hereby release Bellview Pump Sales and Service and its officers, agents, and employees from any liability for the use of any and all of the foregoing information, in consideration for being reviewed for the aforesaid position. Should there be any questions regarding the validity of this release, you may contact me as indicated below.

Full Name

Phone Number

Area CodePhone Number

Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

The following information we are soliciting is strictly voluntary. This form will be kept separate and confidential from the application.

Information provided on this form will not be considered in any employment decision but is for statistical purposes only.

Tilte of Position Applied for:

Date

MonthDayYear

Full Name

First NameLast Name

Age

Gender

MaleFemale

Race/Ethnic Origin (Select ONLY One)

White (not of Hispanic origin): Persons having origins in any of the original people of Europe, North Africa, or the Middle East.Black (not of Hispanic origin): Persons having origins in any of the black racial groups of Africa.Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins regardless of race.Asian or Pacific Islander: Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.American Indian or Alaskan Native: Persons having origins in any of the original people of North American and who maintain cultural identification through tribal affiliation or community recognition.

How did you learn about this position?

Do you have any physical or mental disabilities which may limit your ability to perform essential functions of this job or which would require any special accommodations?

YesNo

If Yes, Please explain:

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Bellview Pump Sales & Service

Education:

Professional License or Certificate, If Required

Skills

Employment History

Personal References

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