APPLICATION FOR EMPLOYMENT

Client
8762 Hwy 182 Opelousas, LA 70570

Phone: (337) 942-2005
EQUAL EMPLOYMENT OPPORTUNITY
In compliance with federal and state equal employment opportunity laws, qualified applicants are considered for all positions without regard to race creed, color religion, sex, national origin, ancestry, age, marital status, affection or sexual orientation, veteran's status, or the presence of a non-job related medical condition or handicap / disability. NOTICE: To be considered a bona fide application for employment, this form must be legible, filled out completely, signed, and position applied for must be specified.
Date of Application

MonthDayYear
Date
Referral Source: How did you hear about this position?
Position Applied For
Prefix
Applicant First Name
Applicant Middle Initial
Applicant Last Name
Suffix or Credentials
SSN
Applicant Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you 18 years of age or older?

YesNo
Are you entitled to work in the United States?

YesNo
Applicant Home Phone
Applicant Mobile Phone
What type of work are you seeking?
Have you been convicted of a felony or been incarcerated in connection with a felony in the last 7 years?

YesNo
If yes please explain
Answering “Yes” to this question is not an automatic bar to employment. Arrest records and juvenile, sealed, and expunged records should not be disclosed.
Military Service?

YesNo
Branch
Military Service Duties
If yes, give dates (FROM)

MonthDayYear
Military From Date
If yes, give dates (TO)

MonthDayYear
Military To Date
Active Reserve?

YesNo
Have you worked here before?

YesNo
If yes give dates (FROM)

MonthDayYear
Worked Here From Date
If yes give dates (TO)

MonthDayYear
Worked Here To Date
Have you applied with us before?

YesNo
If yes give dates (APPLIED FROM)

MonthDayYear
Applied From Date
If yes give dates (APPLIED TO)

MonthDayYear
Applied To Date
Date Available to Start Work

MonthDayYear
Date
Do you have work transportation?

YesNo
Are you willing to work Rotating Shifts?

YesNo
Are you willing to work Weekends?

YesNo
Are you Employed Now?

YesNo
Expected Weekly Earnings
Expected Hourly Rate
EMPLOYMENT HISTORY
Current Employer
Current Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Employer From

MonthDayYear
Date
Current Employer To

MonthDayYear
Date
Current Employer Phone
Please enter a valid phone number.
Name of Immediate Supervisor in Current Position
Current Position and Job Title
Duties and Responsibilities
Current Pay
Select Current Pay Rate Per:
Reason for Leaving Current Employer
Days Absent in the Past Year
May we Contact Current Employer?
Last Prior Employer 1

Tell us where you worked before your current employer
Last Prior Employer Name
Last Prior Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Prior Employer Worked From Date

MonthDayYear
For this prior Employer
Last Prior Employer Worked To Date

MonthDayYear
For this Employer
Last Prior Employer Phone
Valid phone number for this Prior Employer
Name of Immediate Supervisor in this Last Prior Employer Position
Last Position and Job Title at this Prior Employer
Last Duties and Responsibilities at this Prior Employer
Last Rate of Pay at this Prior Employer
Select Prior Employer Pay Method
Reason for Leaving This Prior Employer
Days Absent in the Past Year at this Prior Employer
May we Contact this Prior Employer?
Prior Employer 2

Tell us about your second prior employer
Last Prior Employer Name 2
Last Prior Employer Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Prior Employer Worked From Date 2

MonthDayYear
For this prior Employer
Last Prior Employer Worked To Date 2

MonthDayYear
For this Employer
Last Prior Employer Phone 2
Valid phone number for this Prior Employer
Name of Immediate Supervisor in this Last Prior Employer Position 2
Last Position and Job Title at this Prior Employer 2
Last Duties and Responsibilities at this Prior Employer 2
Last Rate of Pay at this Prior Employer 2
Select Prior Employer Pay Method 2
Reason for Leaving This Prior Employer 2
Days Absent in the Past Year at this Prior Employer 2
May we Contact this Prior Employer? 2
Prior Employer 3
Last Prior Employer Name 3
Last Prior Employer Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Prior Employer Worked From Date 3

MonthDayYear
For this prior Employer
Last Prior Employer Worked To Date 3

MonthDayYear
For this Employer
Last Prior Employer Phone 3
Valid phone number for this Prior Employer
Name of Immediate Supervisor in this Last Prior Employer Position 3
Last Position and Job Title at this Prior Employer 3
Last Rate of Pay at this Prior Employer 3
Select Prior Employer Pay Method 3
Reason for Leaving This Prior Employer 3
May we Contact this Prior Employer? 3
Prior Employer 4
Last Prior Employer Name 4
Last Prior Employer Address 4

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Prior Employer Worked From Date 4

MonthDayYear
For this prior Employer
Last Prior Employer Worked To Date 4

MonthDayYear
For this Employer
Last Prior Employer Phone 4
Valid phone number for this Prior Employer
Name of Immediate Supervisor in this Last Prior Employer Position 4
Last Position and Job Title at this Prior Employer 4
Last Rate of Pay at this Prior Employer 4
Select Prior Employer Pay Method 4
Reason for Leaving This Prior Employer 4
May we Contact this Prior Employer? 4
SKILLS
SKILLS
List any Skills and Qualifications which may assist us in determining your suitability for the position
CERTIFICATIONS AND LICENSES
List Licenses or Certifications with active dates through dates of expiration
State any additional vocational or technical training job training or information you feel may be helpful to us in considering your application for the position
EDUCATION
High School Name and Location
List name of school, street address, city, state, zip
High School Grade Completed

9th Grade10th Grade11th Grade12th Grade
Area of Study
Diploma or Degree
Graduated High School?

YesNo
College or University Name and Location
List name of school, street address, city, state, zip
College or University Years Completed

1 Year2 Years3 Years4 Years
Area of Study
Diploma or Degree
Graduated College or University?

YesNo
Trade School Name and Location
List name of school, street address, city, state, zip
Length of time in Trade School
How long was your training education in this school?
Area of Study
Diploma or Degree
Graduated Trade School?

YesNo
Other School Name and Location
List name of school, street address, city, state, zip
Length of time in Other School
How long was your training education in this school?
Area of Study
Diploma or Degree
Graduated This School?

YesNo
List any applicable special skills, training or proficiencies from education received.
REFERENCES
Reference 1 Full Name
First and Last Name of your first reference
Reference 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 1 Phone Number
Please enter a valid phone number.
Reference 1 Email
example@example.com
Reference 2 Full Name
First and Last Name of your first reference
Reference 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 2 Phone Number
Please enter a valid phone number.
Reference 2 Email
example@example.com
Reference 3 Full Name
First and Last Name of your first reference
Reference 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 3 Phone Number
Please enter a valid phone number.
Reference 3 Email
example@example.com
UPLOAD DOCUMENTS

(Applicant: Check Job Posting for Document Requirements)
Upload Cover Letter

OPTIONAL COVER MAY BE UPLOADED HERE
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Upload Resume

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Upload Licenses or Certifications

(OPTIONAL) DOCUMENT UPLOADED HERE
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Upload ID Document

(OPTIONAL) DOCUMENT UPLOADED HERE
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APPLICANT'S STATEMENT
I certify that answers and statements given herein are true and correct to the best of my knowledge.

I authorize background checks and investigations by the company or its designated agent into previous employment, character,abiity, education and eason for leaving previous employers. By signing this application for employment, I expressly grant all previous employers the right to release all lawful information to the company or its agent, with whom I am seeking employment.

This application for employment shall be considered active for a period not to exceed 90 days.

I hereby understand and acknowledge that, unless otherwise specified or defined, any employment relationship with this company is of an "at will" nature, which means that the meployee may resign at any time and the employer may discharge emplolyee at any time with or without cause. It is further understood and agreed this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically addressed and acknowledged in writing by an authorized executive and officer of this company.

By clicking the submit button below, I certify that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, regardless of when such fact or information may be discovered by the company, my application may be rejected and, if I am employed, my employement may be terminated at any time.

I understand and agree to abide by all rules, regulations and directives of the company as a condition of employment.

I have reviewed and understand the Applicant's Statement section of this application form.
Applicant Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

EQUAL EMPLOYMENT OPPORTUNITY

EMPLOYMENT HISTORY

Last Prior Employer 1

Prior Employer 2

Prior Employer 3

Prior Employer 4

SKILLS

EDUCATION

REFERENCES

UPLOAD DOCUMENTS

APPLICANT'S STATEMENT