APPLICATION FOR EMPLOYMENT
This application is provided by (Company Name). This form complies with federal and state laws against discrimination. Complete all
information requested by printing in ink. We are an equal opportunity employer, dedicated to a policy of nondiscrimination in employment
on any basis including race, color, age, gender, religion, disability, or national origin.
Applicant Information
First
Name
Last Name
Street Address
Apartment/Unit #
City
State
Phone (s)
E-mail Address
ZIP
Position
Applying
Social Security
Are you a citizen of the United States?
Today’s
Date
M.I.
YES
NO
Desired
Salary
$
If no, are you authorized to work in the
YES
U.S.?
NO
SELF IIDENTIFICATION
Gender
Male
Female
Birth Date (mm/dd/yyyy)
Ethnic Origin
Hispanic
Asian
White
P. Islander
African American
Other
How did you first find out about this job? Please check one.
Employee Referral________________________
Job Fair
Professional Publication
Television
Newspaper
College/University Career Day
Radio
WorkInTexas.com
Other (specify): ____________________________
EDUCATION AND TRAINING
Yes
High School Graduate Or General Education (GED) Test Passed?
If no, list the highest grade completed
No
College, Business School, Military (Most recent first)
Dates
Attended
Month/Year
Name and Location
From
To
From
To
Degree
& Year
Graduate
Major
or Subject
Yes
No
Yes
No
Occupational License, Certificate or Registration
Num
ber
Where Issued
Expiration Date
DRIVER’S LICENSE (Only for positions which require driving, driving record from DPS for 10 years required)
Do you have a driver’s license?
Driver’s license
number
Yes
No
State of issue
Operator
Commercial (CDL)
Chauffeur
Expiration date
Have you had any accidents during the past three years?
Yes
No
How many?
MILITARY
Are you a veteran of the United States military service?
Yes
No If yes, what branch?
If yes, Date Entered
Date Discharged
If yes, please describe any special skills or training acquired while in the service:
Revised 2018
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SPECIAL SKILLS (List all pertinent skills and equipment that you can operate)
(Maximum 1000 characters)
WORK EXPERIENCE (Most Recent First) (Include voluntary work and military experience)
(
)
Employer
Address
Telephone Number
Job Title
Specific Duties (Maximum 1000 characters)
Number Employees Supervised
-
From (Month/Year)
To (Month/Year)
Hours Per Week
Last Salary
Supervisor
Reason For Leaving
May We Contact This Employer?
(
)
Employer
Address
Telephone Number
Job Title
Specific Duties (Maximum 1000 characters)
Number Employees Supervised
-
Yes
No
From (Month/Year)
To (Month/Year)
Hours Per Week
Last Salary
Supervisor
Reason For Leaving
May We Contact This Employer?
Employer
Address
Telephone Number
Job Title
Specific Duties (Maximum 1000 characters)
(
)
Number Employees Supervised
-
Yes
No
From (Month/Year)
To (Month/Year)
Hours Per Week
Last Salary
Supervisor
Reason For Leaving
May We Contact This Employer?
Yes
REFERENCES
Please list two references other than relatives
Name
_______
Name
Position
Position
Company
Company
Address
Address
Telephone (
Revised 2018
)
Telephone (
)
Page 2 of 3
No
WAIVERS AND DISCLOSURES
Please read each section carefully and sign where indicated.
AT-WILL EMPLOYMENT
It is my understanding that this employment application, or the granting of an oral interview, does not represent a
contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired, my
employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my
employer. I also understand that this written statement supersedes any and all oral representations made by agents or
representatives of this organization.
CERTIFICATION OF TRUTH AND ACCURACY
I certify that the information in this application is true, complete and correct. I understand that false answers, statements,
or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.
Drug and Alcohol
Potential candidates are required to submit to a pre-placement physical and drug screening as a condition of
employment. (Company Name) exercises the right to require post-accident drug screens and random testing at its
discretion. Illegal or unauthorized possession or use, sale or distribution of drugs or alcohol is not permitted on any of
LSEF premises
NOTIFICATION AND AUTHORIZATION TO REQUIRE A MEDICAL EXAMINATION
I hereby certify that, if hired, I will disclose any limitations I have that may impact my ability to do the job. I understand
that I may also be required to undergo a pre-employment or post-employment medical exam by a designee of Leader
Gasket Technologies, Inc. designated health practitioner.
NOTIFICATION AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION
I understand that I may be subject to a background check, and hereby authorize (Company Name), investigate my
background to determine any and all information of concern as to my record, whether same is of record or not, and I
release employers and persons named in my application from all liability for any damages on account of his/her
furnishing said information.
Additionally, you are hereby authorized to make any investigation of my personal history, educational background,
military record, motor vehicle records, and criminal records history through an investigative or credit agency or bureau of
your choice. I authorize the release of this information by the appropriate agencies to the investigating service. This
authorization, in original or copy form, shall be valid for this and for any future reports and updates that may be required.
I understand that passing the background check is a condition of employment. A negative background check can be
grounds for dismissal, even if an offer has been made to me and I have been hired.
Non-Discrimination Policy
(company name), is committed to the principle of equal opportunity in education and employment. (company name)
does not discriminate on the basis of sex, race, color, creed, national origin, age, religion, sexual orientation, gender
identity, gender expression, veteran status, or disability in admission to, access to, treatment in, or employment in its
programs and activities.
I certify the information contained in this application is true, correct, and complete. I understand that, if employed, false
statements reported on this application may be considered sufficient cause for dismissal.
Signature of Applicant_______________________________________________________
Revised 2018
Date________________
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