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EMPLOYMENT APPLICATION
EQ U AL OPPORTU NITY EMPLOYER. Fac ility In teriors , In c . is an eq u al op p ortu n ity em p loy er. It is th e C om p an y ’s p olic y to ab id e b y all Fed eral an d S tate law s p roh ib itin g em p loy m en t d is c rim in ation s olely on th e b as is of a p ers on ’s rac e, c olor, c reed , n ation al origin , religion , age (ov er 4 0), s ex , m arital s tatu s , p h y s ic al or m en tal d is ab ility , or v eteran s tatu s ex c ep t w h ere a reas on ab le, b on a fid e oc c u p ation al q u alific ation ex is ts .
To b e c o n s id e r e d fo r e m p lo y m e n t th is a p p lic a tio n m u s t b e c o m p le te d in its e n tir e ty . (Please print in ink)
T od ay ’s D ate _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , 20_ _ _ _ _
N am e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S oc ial S ec u rity # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Ad d res s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N u m b er of Y ears _ _ _ _ _ _ _ _ _ _ _ _
C ity _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S tate & Z ip C od e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
H om e Ph on e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D ay Ph on e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Prev iou s Ad d res s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N u m b er of Y ears _ _ _ _ _ _ _ _ _ _ _
Pos ition ap p lied for: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Are y ou av ailab le for fu ll-tim e w ork ? _ _ _ _ _ _ Y es _ _ _ _ _ _ N o If n ot, w h at h ou rs an d d ay s are y ou av ailab le? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D ate av ailab le to b egin w ork _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ M in im u m s alary req u irem en t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ED U CATION AND TRAINING
Prin t S c h ool N am e, C ity & S tate D egree/M ajor/C ou rs e of S tu d y
H igh S c h ool
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
C ollege
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
G rad u ate S c h ool
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
T rad e S c h ool
L is t an y oth er ed u c ation , train in g, s p ec ial s k ills or c ertific ates /lic en s ees th at y ou p os s es s . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
L is t an y m ac h in es or eq u ip m en t on w h ic h y ou are q u alified an d ex p erien c ed in op eratin g _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
L is t an y lan gu ages th at y ou flu en tly s p eak _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ R ead /w rite _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D o y ou h av e a v alid d riv er’s lic en s e? _ _ _ _ _ _ Y es _ _ _ _ _ _ N o If y es , lis t s tate an d n u m b er _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
FIEA-09-25-13 Page 1 of 3

G ENERAL INFORMATION
C an y ou , after em p loy m en t, v erify y ou r legal righ t to w ork p erm an en tly in th e U n ited S tates ? _ _ _ _ _ _ Y es _ _ _ _ _ _ N o
M ilitary ex p erien c e? _ _ _ _ _ _ Y es _ _ _ _ _ _ N o If y es , w h at b ran c h ? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
L is t y ou r ran k at s ep aration _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
H av e y ou ev er b een c on v ic ted of a felon y , or p lead ed n o c on tes t to a felon y , or b een c on v ic ted of a m is d em ean or res u ltin g in im p ris on m en t or a fin e ov er $ 500 d u rin g th e las t ten y ears ? ( Criminal convictions are not an automatic disqualification for employment, but will be considered only in relation to specific job requirements.) _ _ _ _ _ _ Y es _ _ _ _ _ _ N o
If y es , p leas e ex p lain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
C an y ou p erform th e es s en tial fu n c tion s of th e job ? _ _ _ _ _ _ Y es _ _ _ _ _ _ N o
D o y ou req u ire an y ac c om m od ation s to p erform th e es s en tial fu n c tion s of th e job ? _ _ _ _ _ _ Y es _ _ _ _ _ _ N o
If y es , p leas e ex p lain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
EMPLOYMENT H ISTORY
L is t all w ork ex p erien c e b egin n in g w ith th e p res en t an d m os t rec en t job (u s e b ac k of ap p lic ation , if n ec es s ary ).
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N AM E O F EM PL O Y ER T Y PE O F B U S IN ES S
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
AD D R ES S C IT Y S T AT E Z IP
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D AT ES EM PL O Y ED (FR O M – T O ) T IT L E
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N AM E & T IT L E O F S U PER V IS O R T EL EPH O N E N U M B ER
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
B R IEF D ES C R IPT IO N O F D U T IES
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
R EAS O N F0R L EAV IN G L AS T S AL AR Y
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N AM E O F EM PL O Y ER T Y PE O F B U S IN ES S
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
AD D R ES S C IT Y S T AT E Z IP
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D AT ES EM PL O Y ED (FR O M – T O ) T IT L E
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N AM E & T IT L E O F S U PER V IS O R T EL EPH O N E N U M B ER
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
B R IEF D ES C R IPT IO N O F D U T IES
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
R EAS O N FO R L EAV IN G L AS T S AL AR Y
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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N AM E O F EM PL O Y ER T Y PE O F B U S IN ES S
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
AD D R ES S C IT Y Z IP
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D AT ES EM PL O Y ED (FR O M – T O ) T IT L E
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N AM E & T IT L E O F S U PER V IS O R T EL EPH O N E N U M B ER
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
B R IEF D ES C R IPT IO N O F D U T IES
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
R EAS O N FO R L EAV IN G L AS T S AL AR Y
REFERENCES ( L ist th ree individuals – not employers or relatives – k nown to you for a minimum of th ree years.)
N AM E & AD D R ES S O C C U PAT IO N PH O N E N U M B ER
1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
EMERG ENCY CONTACT
N am e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T elep h on e N u m b er _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Ad d res s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
AG REEMENT Pleas e read th e follow in g s tatem en t c arefu lly .)
I h ereb y affirm th at th e in form ation p rov id ed on th is ap p lic ation (an d ac c om p an y in g res u m ed , if an y ) is tru e an d c om p lete to th e b es t of m y k n ow led ge. I als o agree th at fals ified in form ation or s ign ific an t om is s ion s m ay d is q u alify m e from fu rth er c on s id eration for em p loy m en t an d m ay b e c on s id ered ju s tific ation for d is m is s al if d is c ov ered at a later d ate.
I au th oriz e all p ers on s lis ted ab ov e (an d on th e ac c om p an y in g res u m e, if an y ) to giv e Fac ility In teriors (FI) an y an d all in form ation c on c ern in g m y p rev iou s em p loy m en t an d ed u c ation an d an y p ertin en t in form ation th ey m ay h av e, p ers on al or oth erw is e, an d releas e all p arties , s u c h p ers on s , an d FI, from liab ility for an y d am age th at m ay res u lt from fu rn is h in g th e s am e to FI.
I u n d ers tan d th at FI w ill p rov id e w ork er’s c om p en s ation or a lik e k in d in s u ran c e c ov erage for its em p loy ees . In th e ev en t of an in ju ry in th e w ork p lac e, I agree th at m y s ole rem ed y lies in c ov erage u n d er FI’s in s u ran c e p olic y .
If em p loy ed b y FI, I agree to c on form to th e ru les an d regu lation s of FI. I fu rth er u n d ers tan d an d ac k n ow led ge th at u n les s oth erw is e d efin ed b y ap p lic ab le law , an y em p loy m en t relation s h ip w ith th is organ iz ation is of an “ at-w ill” n atu re, w h ic h m ean s th at th e Em p loy ee m ay res ign at an y tim e an d th e Em p loy er m ay d is c h arge th e
Em p loy ee w ith or w ith ou t c au s e. I fu rth er u n d ers tan d th at n o m an ager or rep res en tativ e of FI, oth er th an th e C EO of th e C om p an y , h as an y au th ority to en ter in to an y agreem en t, oral or w ritten , for em p loy m en t for an y s p ec ified p eriod of tim e or to m ak e an y as s u ran c e or p rom is e of c on tin u ed em p loy m en t.
If em p loy ed , I u n d ers tan d th at if I w ill b e op eratin g a c om p an y v eh ic le or op eratin g a v eh ic le on th e c om p an y ’s b eh alf, FI, h as b y au th oriz ation to c on d u c t an in v es tigation of m y d riv in g rec ord .
I u n d ers tan d an d agree th at I m ay b e req u ired to tak e a d ru g an d alc oh ol-s c reen in g tes t. I h ereb y giv e m y v olu n tary c on s en t for b lood an d /or u rin e s am p le to b e c ollec ted from m e an d s u b m itted for tes tin g. I als o c on s en t to th e releas e of th e tes t res u lts to FI for its u s e. I u n d ers tan d th at an y p os itiv e d ru g or alc oh ol res u lt m ay p rec lu d e m y em p loy m en t.
S ign atu re _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D ate _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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NOTICE TO J OB APPLICANT
CONSENT FORM
F ac ility I nterio rs w ill b e v erify in g c ertain in form ation c on tain ed in y ou r ap p lic ation for em p loy m en t, c on d ition al job offer or p rov id ed b y y ou d u rin g th e in terv iew p roc es s . T h e in form ation req u es ted b elow is n ec es s ary to c om p lete th is tas k . T h is in form ation is N O T a p art of th e ap p lic ation for em p loy m en t an d w ill b e u s ed for th e s ole p u rp os e of v erific ation of in form ation , an d s tatem en ts m ad e b y y ou .
( P lease complete all information requested.)
Ap p lic an ts L egal N am e:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
L ast F irst M .I.
Pleas e p rov id e an y oth er n am e u s ed for p rior em p loy m en t or s c h ool th at d ifferen tiates from ab ov e:
N am e:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
L ast F irst M .I.
C u rren t H om e Ad d res s :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
S treet City/S tate Z ip
D ate of B irth :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S oc ial S ec u rity # :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M onth /D ay/Y ear
D riv er’s L ic en s e # :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S tate:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Re s id e n tia l H is to r y : (L ist all resid ential ad d resses in th e last 7 y ears)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ From :_ _ _ _ _ _ _ _ _ _ _ _ _ _ T o:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Ad d res s C ity S tate Z ip
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ From :_ _ _ _ _ _ _ _ _ _ _ _ _ _ T o:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Ad d res s C ity S tate Z ip
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ From :_ _ _ _ _ _ _ _ _ _ _ _ _ _ T o:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Ad d res s C ity S tate Z ip
It is p os s ib le th at y ou r em p loy m en t m ay b e d eterm in ed in w h ole or in p art b y y ou r p ros p ec tiv e em p loy er u s in g d ata from th is b ac k grou n d c h ec k . Pu rs u an t to S ec tion 6 09 of th e Fair C red it R ep ortin g Ac t, y ou m ay b e en titled to a c op y of th is rep ort.
Ap p lic a n t Co n s e n t: I u n d ers tan d an d agree th at Fac ility In teriors w ill v erify all or p art of th e in form ation I h av e giv en . I u n d ers tan d th at th is v erific ation m ay in c lu d e an in q u iry in to m y c red it h is tory , m otor v eh ic le d riv in g rec ord , c rim in al an d c iv il rec ord s , p rior em p loy m en t (in c lu d in g c on tac tin g p rior em p loy ers ), ed u c ation (d egree, G PA, an d atten d an c e) as w ell as oth er p u b lic rec ord in form ation .
I au th oriz e th e releas e of s u c h in form ation as m ay b e n ec es s ary to v erify th e in form ation I h av e p rov id ed . I releas e an d h old h arm les s from all liab ility an y in d iv id u al or en tity req u es tin g or s u p p ly in g in form ation w ith res p ec t to m y ap p lic ation for em p loy m en t.
Ap p lic an t’s S ign atu re:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D ate:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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