Television Telephone Internet Security
Position Applied For:
Date You Can Start Work -
Month: Day: Year:
Desired Salary:
Yes, I can Work:
Weekends
Evenings
I Would Rather Work:
1st Shift
2nd Shift
3rd Shift
An Interview

Personal Information

Last Name: First Name: Middle Name or Initial:
Address: City: State & Zip:
Home Phone Number: Mobile or Work Phone Number:
Email:

Additional Questions

Please answer all of the following questions.
Use the Comments section for explanations.

Are you at least 18 years of age and legally eligible for work in the United States? Yes
No
Will you work overtime when necessary? Yes
No
Do you have reliable transportation to and from work? Yes
No
Do you have a current and valid driver's license? Yes
No
- If yes, State of Issue:
- If yes, License Number:
Have you been convicted of or pled guilty to any traffic-related offenses within the last five years? Yes
No
Have you had your driver's license suspended, revoked or modified by a court of law? Yes
No
Are you currently bound by a non-competition or trade secret agreement? (If yes, explain in the comments section bellow) Yes
No
Have you been previously employeed by this organization or one of our affiliates? (If yes, explain in the comments section bellow) Yes
No
Are you currently on "lay-off" status with another company and subject to recall? Yes
No
If you are currently employed, may we contact your present employer? Yes
No
N/A

Employment History (Begin with Most Recent)

Title:
Company:
Address:
Start Date:
Month: Day: Year:
End Date:
Month: Day: Year:
Rate of Pay:
Supervisor:
Phone Number:
Reason for Leaving:
Responsibilities:
Title:
Company:
Address:
Start Date:
Month: Day: Year:
End Date:
Month: Day: Year:
Rate of Pay:
Supervisor:
Phone Number:
Reason for Leaving:
Responsibilities:
Title:
Company:
Address:
Start Date:
Month: Day: Year:
End Date:
Month: Day: Year:
Rate of Pay:
Supervisor:
Phone Number:
Reason for Leaving:
Responsibilities:

Education:

High School Attended:
Address:
Course of Study:
Did you Earn a Diploma? Yes
No
College/Technical School Attended:
Address:
Course of Study:
Did you Earn a Degree/Certificate/Diploma? Yes
No
College/Technical School Attended:
Address:
Course of Study:
Did you Earn a Degree/Certificate/Diploma? Yes
No
Graduate School Attended:
Address:
Course of Study:
Did you Earn a Degree/Certificate/Diploma? Yes
No
Are you planning to pursue further studies?
If so, when and what courses?
Describe any job-related training,
apprenticeship, skills, licenses,
certificates or qualifications
acquired from formal education or
other employment.

Comments and/or Detail to Questions

Acknowledgement of Understanding By applicant

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and referenes. I also hereby release from liablility Gearheart Communications, Inc. and its representatives for seaking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whnever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.


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