Contact Information First Name Last Name Address City State Zip Home Phone Mobile Email Application Information Referral Attachments Resume Cover Letter Personal Information Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment) YesNo Are you at least 18 years or older? (If no, you may be required to provide authorization to work) YesNo Have you ever been convicted of a felony? YesNo If Yes, please explain. Have you ever worked for this Company before?YesNo If Yes, please provide details (Where/ When/ Job Title) Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?YesNo If no, please explain. PEC SAFELAND CARD # Employment Desired When would you be available to begin work? Hourly rate/salary desired Are you currently employed?YesNo if so may we inquire of your present employer?YesNo If presently employed, why are you considering leaving? Employment History (starting with current or most recent employment) Dates employed (From-to) Employer Name & Address Employer phone Job Title Supervisor Name & Title May we contact?YesNo Responsibilities reason for leaving Salary/ Hourly Rate (Start-End) Dates employed (From-to) Employer Name & Address Employer phone Job Title Supervisor Name & Title May we contact?YesNo Responsibilities reason for leaving Salary/ Hourly Rate (Start-End) Dates employed (From-to) Employer Name & Address Employer phone Job Title Supervisor Name & Title May we contact?YesNo Responsibilities reason for leaving Salary/ Hourly Rate (Start-End) Dates employed (From-to) Employer Name & Address Employer phone Job Title Supervisor Name & Title May we contact?YesNo Responsibilities reason for leaving Salary/ Hourly Rate (Start-End) Additional Qualifications List any Experience and Training that may qualify you to work for us: If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe: Education School or College # Years Degree School or College # Years Degree School or College # Years Degree References- Please provide three references (not relatives). Name Relationship Phone Number Email Name Relationship Phone Number Email Name Relationship Phone Number Email Driving Questions Do you have a valid Driver's License?YesNo class:ABC Do you currently have reliable transportation?YesNo Equal Opportunity Employment WE ARE AN EQUAL OPPORTUNITY EMPLOYER AND DO NOT DISCRIMINATE ON THE BASIS OF RACE, ANCESTRY, COLOR, RELIGION, SEX, AGE, MARITAL STATUS, SEXUAL ORIENTATION, NATIONAL ORIGIN, MEDICAL CONDITION, DISABILITY, VETERAN STATUS, OR ANY OTHER BASIS PROTECTED BY LAW. THE INFORMATION PROVIDED WILL BE USED FOR RESEARCH, REPORTING, STATISTICAL PURPOSES AND TO MONITOR LEGAL COMPLIANCE. TO HELP US COMPLY WITH THESE GOVERNMENT REQUIREMENTS, PLEASE COMPLETE THE FOLLOWING INFORMATION. COMPLETION OF THIS FORM IS VOLUNTARY AND WILL NOT AFFECT YOUR OPPORTUNITY FOR EMPLOYMENT OR TERMS OR CONDITIONS OF EMPLOYMENT IF HIRED. WE APPRECIATE YOUR COOPERATION. Authorization The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary. I understand that I am required to abide by all rules and regulations of the company. Signature (type name) Date
