REGULAR APPLICATION

Full Name*

First NameLast Name

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Referred by

Position Desired*

Desired Start Date*

MonthDayYear

Salary Desired

Are you employed?*

YesNo

If so, may we inquire of your present employer?*

YesNo

Ever applied to this company before?*

YesNo

If yes, where and when?*

HIGH SCHOOL*

COLLEGE*

TRADE SCHOOL*

Please list any special training/skills or courses that you have taken.

US Military or Naval Service?

Rank?

Please list your last 4 former employers below, starting with the most recent or current employer first. Please include: Company name and Address, salary, position and your reason for leaving. *

Please list the names of three references, not related to you, whom you have known for at least 3 years?*

AUTHORIZATION

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements containerd herein and the references and employers listed above to giv eyou any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized comapny representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevent federal and state laws.

Date*

MonthDayYear

Signature

PENNSYLVANIA CRMINAL RECORD CHECK AFFIDAVIT

I hereby authorize George Leck & Son Inc. to complete a Pennsylvania state criminal record check for employment purposes. I understand that George Leck & Son Inc. will use this information for prior employment screen purposes only and will not release this information to any other person's or agencies. I also understand that in the event of a criminal record existing that George Leck & Son Inc. holds the right to deny employlent based on facts received in the record check. I also understand that a refusal to complete this affidavit will give George Leck & Son Inc a course of action to refuse employment to me with their company.

Signature

Date

MonthDayYear

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT & AUTHORIZATION

Disclosure

It is George Leck & Son Inc's company policy to perform certain background checks of its employees and applicants. This may include checking your previous employment, criminal and civil history, drug/alcohol test records, educational records, driving reocrds and credit history, etc. The report may contain information on your character, general reputation, personal characteristics and mode of living. In it, you may be the subject of a "consumer report" or an "investigative consumer report". The latter is obtained through personal interviews. We will use this information as part of the basis of our decision regarding your employment. Thus meants that your former employers and others may be contacted and a search of public and private recrds made. We may not obtain this information without your express written consent. You do have to consent; however, you will not be eligible for employment unless you agree to pay us to obtain this information. To help us ontain this information was sometimes use a consumer reporting agency. That agency is Concorde, Inc., 1835 Market Street, 12th Floor, Philadelphia, PA 19103, 215-563-555 or 888-805-8885; www.concorde2000.com. In the event that we intend to make an adverse decision based on any information obtained, we will tell you and provide you with a copy of what we obtain; we will provde a copy of your rights in the form prescribed by the Consumer Financial Protection Bureau. If you would like a copy of any Report that we receive, you can obtain a copy by making that request to us in writing at this time.

Acknowledgement and Authorization

I acknowledge receipt of A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT. I authorize Company and Concorde to make lawful inquiries, including of my prior employers, and other entities and persons to verify my suitability for employment. This may include requests for information regarding my criminal, civil and motor vehicle records. I authorize the release of this information by any prior employer and anyone else having information or documentation about me to Company and Concorde. I authorize Concorde or other consumer reporting agencies to provide consumer and investigative consumer reports to you. I agree that so long I remain employed by the above named employer, this this Disclosure and Authorization shall remain in the effect and accordingly, it shall not be necessary for me to sign a new Disclosure and Authorization.

Full Name

First NameLast Name

Birthdate

MonthDayYear

Social Security Number

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Former Addresses for Last 7 Years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Former Addresses for Last 7 years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Resume

Upload a File

Have you also submitted a hard copy of your resume?

YesNoNot sure

Signature

Date

MonthDayYear

Regular Application

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION HISTORY

GENERAL INFORMATION

FORMER EMPLOYEES