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2200 Old Missouri Rd.
Suite C Springdale, AR 72764
(479) 751-9591
(479) 756-3325 Fax
Mon - Fri: 8:00 - 5:00
Closed For Lunch 12-1
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Secure Application For Employment
Full Name
Date
Street Address
City, State, & Zip Code
Phone Number
Social Security Number
If hired can you provide proof that you are of legal working age?
No
Yes
Are you currently employed?
No
Yes
Day you would be able to start work?
Rate of pay expected?
Have you ever filled out an application for, or been employed by, this company?
No
Yes
Elementary/High School (Number of years completed)?
College/Vocational (Number of hours completed)?
Field of study?
List any other educational background
Most Recent Employer #1 Name
Most Recent Employer Telephone Number
Most Recent Employer Start Date
Most Recent Employer End Date
Most Recent Employer Rate of Pay
Most Recent Employer Description of Duties
Most Recent Employer Reason For Leaving?
Employer #2 Name
Most Recent Employer #2 Telephone Number
Most Recent Employer #2 Start Date
Most Recent Employer #2 End Date
Most Recent Employer #2 Rate of Pay
Most Recent Employer #2 Description of Duties
Most Recent Employer #2 Reason For Leaving?
Employer #3 Name
Most Recent Employer #3 Telephone Number
Most Recent Employer #3 Start Date
Most Recent Employer #3 End Date
Most Recent Employer #3 Rate of Pay
Most Recent Employer #3 Description of Duties
Most Recent Employer #3 Reason For Leaving?
Amount of time lost from work during the past two years? Please explain.
Have you ever been convicted of a crime?
No
Yes
Have you ever been convicted of a crime, please explain if answered yes.
Acceptance of terms (Please check the box):
I hereby affirm the information given by me on this application for employment is complete and accurate. I understand any falsification or ommisions will be immediate grounds for dismissal. I authorize a thorough investigation to be made in connection with this application concerning my character, general reputation, personal characteristics, employment and educational background, any criminal record, and mode of living, whichever may be applicable. I hereby authorize the release of documents and personal interviews with third parties, such as prior employers, family members, business associates, financial sources, friends, neighbors, or others with whom I am acquainted. I further understand I have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of the nature and scope of this investigation. It is understood, as a condition of initial or continued employment, I agree to submit to such lawful examinations, medical, substance abuse, or other as may be required by the company. The company will pay the reasonable cost of any such examination which may be required. If I am hired, I agree my employment and compensation can be terminated with or without cause and without notice, at any time, at the option of this company or myself. I understand no manager or other representative other thatn the president or vice-president, and in writing, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.
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