Y-Delta, Inc. Employee Application

Y-Delta, Inc.

Application for Employment
TODAY’S DATE

MonthDayYear
Date
NAME
SOCIAL SECURITY #
DRIVERS LICENSE #
ADDRESS
TELEPHONE
POSTION APPLYING FOR
SPECIAL QUALIFICATIONS
ARE YOU 18 YEARS OR OLDER?
WERE YOU IN ANY ARMED FORCES SERVICE? IF YES PLEASE ANSWER BELOW QUESTIONS
BRANCH OF SERVICE
DUTIES
RANK AT TIME OF ENLISTMENT
RANK AT TIME OF DISCHARGE
DO YOU HAVE ANY PHYSICAL LIMITATIONS THAT PROHIBIT YOU FORM PERFORMING ANY WORK FOR WHICH YOU ARE BEING CONSIDERED?
YES
NO
IF YES, WHAT CAN BE DONE TO ACCOMADATE YOUR LIMITATION?

EDUCATION

	YEARS ATTENDED	NAME OF SCHOOL	CITY	COURSE	DID YOU GRADUATE?
COLLEGE
HIGH SCHOOL

*THE AGE DISCRIMINATION IN EMPLOYMENT ACT OF 1967 PROHIBITS DISCRIMINATION ON THE BASIS OF AGE WITH RESPECT TO INDIVIDUALS WHO ARE AT LEAST 40 BUT LESS THAN 70 YEARS OF AGE. *
EXPERIENCE

	NAME AND ADDRESS OF COMPANY:	DATES WORKED	LIST YOUR DUTIES:	STARTING SALARY:	FINAL SALARY:	REASON FOR LEAVING:
#1
#2
#3

BUSINESS REFERENCES
NAME, ADDRESS, OCCUPATION, CONTACT INFO
NAME, ADDRESS, OCCUPATION, CONTACT INFO
Employment Background Investigation Authorization
I understand that an investigative report may be generated on me that may include information as to my character, work habits, performance and experience, along with reasons for termination of past employment, criminal history records from any criminal justice agency in any or all federal, state, city, and county jurisdictions, state Department of Motor Vehicle/ Driver’s License Records to include traffic citations and registration, military records from the National Personnel Record Center, education records including transcripts, and request for records and information from any individual, company, firm, corporation, present and/ or past employers and public agencies (including Social Security Administration and the Immigration & Naturalization Services I fully understand that Y-Delta, Inc. and/or their agents may be requesting information from public and private sources about any of the information noted earlier in this paragraph, and I freely give my consent for Y-Delta, Inc., and any of their agents to do so.

I agree that a photocopy or telephonic facsimile of this authorization shall be valid as the original. This release is valid for most, federal, state, city, and county agencies.

I hereby authorize, without reservation, anyone contacted by Y-Delta, Inc. and/or their agents to furnish the information described in Section I.

I hereby authorize, without reservation, Y-Delta, Inc. and/or their agents to contact my present employer or past employes for employment verification and references.
Applicant, Please Complete the Following:
Signature

Clear
Today’s Date

MonthDayYear
Date
Please print full legal name
The following information is required by law enforcement agencies and other positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.
Please print other names you have used
SOCIAL SECURITY #
Date of Birth

MonthDayYear
Date
**The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. Your date of birth is required on this form in order to confirm your identity for purposes of completing an accurate background investigation, and is not provided for any purposes in connection with consideration of your application for employment.**
ADDRESS
CITY
STATE
ZIP/POSTAL CODE
DRIVERS LICENSE NUMBER & STATE, NAME AS APPEARS ON LICENSE
Have you ever been convicted of, please guilty, or “no contest” to a crime that has or has not been expunged or removed from your record? NO or YES
If YES, please explain
(Y-Delta, Inc. will consider the nature of the offense, relation to the position for which you are applying, time since conviction, and all other relevant facts and circumstances in determining whether or not to disqualify you from consideration

DRIVERS PRIVACY PROTECTION ACT and ANY APPLICABLE STATE STATUE(S) NOTICE: This information may only be used to verify a statement(s) made by and individual in conjunction with legitimate business needs. The depth of information available varies from state to state. The report that will be generated for employment purposes only and in compliance with the Driver’s Protection Act and any applicable federal or state statue(s
Should be Empty:

Y-Delta, Inc.

EXPERIENCE

BUSINESS REFERENCES

Employment Background Investigation Authorization

Applicant, Please Complete the Following: