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EMPLOYMENT APPLICATION

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION HISTORY

NAME OF SCHOOL LOCATION YEARS ATTENDED DID YOU GRADUATE? SUBJECT STUDIED

GENERAL INFORMATION

RESIDENCY CERTIFICATION

NAME RELATIONSHIP PHONE NUMBER
DATE MONTH AND YEAR NAME & ADDRESS OF EMPLOYER NAME OF SUPERVISOR & PHONE NO. SALARY POSITION REASON FOR LEAVING
FR.
TO
FR.
TO
FR.
TO
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AUTHORIZATION

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal.

"I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company for all liability for any damage that may result from utilization of such information.

"I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disability Act (ADA) and other relevant federal and state laws."