EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION
AG Layne is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, religion, sex, national origin, disability, age, or military or veteran status in accordance with federal law. In addition, AG Layne complies with applicablestateand local law governing non-discrimination in employment in every jurisdiction in which it maintains facilities. AG Layne also provides reasonable accommodation to qualified individuals with disabilities in accordance with applicable laws.
Notice: Applicants considered for employment must take a pre-employment physical which may include a drug screen.
Initial to acknowledge the above*

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Your Name (First, Middle, Last - please populate all fields)*

First nameMiddle InitialLast name
Address*

Street address

Street Address Line 2

City / StateState / Province

Zip
Home Phone*
Mobile Phone*
Email address*
example@example.com
Position applying for*
Shift applying for*

1st2nd
Have you applied with us before?*

YesNo
Date last applied?

MonthDayYear
Date
Social Security number*
Drivers license & State*
Languages Spoken*
Highest Education

High SchoolCollegeSome CollegeDegree
Are you lawfully entitled to work in the U.S.?*

YesNo
What is your desired salary?*
Can you perform the functions of this job?*

YesNo
Are you currently employed?*

YesNo
May we contact your employer?*

YesNo
Supervisor's Name
Supervisor's Phone Number
Employment History
Company
City & State
Date started

MonthDayYear
Date
End date

MonthDayYear
Date
Supervisor Name
Supervisor Phone Number
Reason for leaving
Job Title / Duties:
Do you have more employment history that you would like to add?
Company
City & State
Date started

MonthDayYear
Date
End date

MonthDayYear
Date
Supervisor Name
Supervisor Phone Number
Reason for leaving
Job Title / Duties:
Do you have more employment history that you would like to add?
Company
City & State
Date started

MonthDayYear
Date
End date

MonthDayYear
Date
Supervisor Name
Supervisor Phone Number
Reason for leaving
Job Title / Duties:
Do you have more employment history that you would like to add?
Company
City & State
Date started

MonthDayYear
Date
End date

MonthDayYear
Date
Supervisor Name
Supervisor Phone Number
Reason for leaving
Job Title / Duties:
Describe any specialized training, apprenticeship, skills, and qualifications acquired from employment or other experience.
I certify that the information provided in this employment application, and any other document provided in an effort to gain employment is true, and complete. I also authorize investigation of all statements contained in these documents for employment, as it may be necessary, in arriving at an employment decision. In the event of employments, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand that I am required to abide by all rules and regulations of the employer.
Signature*

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Date*

MonthDayYear
Date
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EMPLOYMENT APPLICATION

Employment History