Employment Application

First Name *

Last Name *

M.I. *

Date *

Street Address *

Apartment/Unit # *

City *

State *

Zipcode *

Phone Number *

Email *

Date Available *

Desired Salary *

Position Applied for *

Are you a citizen of the United States? *

If no, are you authorized to work in the U.S.?

YESNO

Have you ever been convicted of a felony? *

YESNO

EDUCATION

High School *

Address *

From *

To *

Did you graduate?

YESNO

College

Address

From

To

Did you graduate?

YESNO

Other

Address

From

To

Did you graduate?

YESNO

REFERENCES

Please list three professional references.

Full Name *

Relationship *

Company *

Phone *

Address *

Full Name *

Relationship *

Company *

Phone *

Address *

Full Name *

Relationship *

Company *

Phone *

Address *

PREVIOUS EMPLOYMENT

Company *

Phone *

Address *

Supervisor *

Job Title *

Responsibilities *

From *

To *

Reason for Leaving *

May we contact your previous supervisor for a reference? *

YESNO

Supervisor Name *

Supervisor Email *

Supervisor Phone Number *

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YESNO

Supervisor Name *

Supervisor Email *

Supervisor Phone Number *

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YESNO

Supervisor Name *

Supervisor Email *

Supervisor Phone Number *

MILITARY SERVICE

Branch *

From *

To *

Rank at Discharge *

Type of Discharge *

If other than honorable, explain

DISCLAIMER AND SIGNATURE

I hereby authorize Advanced Pipe Repair, Inc. to thoroughly investigate my background, references, employment record and other matters related to my suitability for employment. I authorize persons, schools, my current employer (if applicable) and previous employers and organizations contacted by Advanced Pipe Repair, Inc. to provide any relevant information regarding my current and/or previous employment and I release all person, schools employers of any and all claims for providing such information. I understand that misrepresentation or omission of facts may result in rejection of this application or if hired, discipline up to and including dismissal. I understand that I may be required to sign a confidentiality and/or non-compete agreement should I become an employee of Advanced Pipe Repair, Inc. I understand that nothing contained in this application or conveyed during any interview which may be granted is intended to create an employment contract. I understand that filling out this form does not obligate Advanced Pipe Repair, Inc. to hire me. Advanced Pipe Repair, Inc. is an Equal Opportunity Employer.

Signature *

Date*