Etowah Employment Application

Date:

Full Name:

Are you 18 or older:
 Yes No

Present Address:

City, State:

Zip:

Permanent Address:

City, State:

Zip:

Home Phone:

Cell Phone:

Positions Applied for:

Salary Desired:

 Full-Time Part-Time Full or Part Time
 1st Shift 2nd Shift 3rd Shift 12 Hour Shifts

Hours Available to Work:

When are you available to begin work?

Are you either a US Citizen or an Alien Authorized to work in the US?
 Yes No

Are you Employed?
 Yes No

If so may we inquire of your present employer?
 Yes No

Ever applied to this company before? Where?

When?

Referred By:

Education

Have you ever been convicted of a Felony?
 Yes No

Special Skills:

Do you have a drivers license?
 Yes No

State of issue:

Present Membership in US Military or Naval Service?

Rank?

National Guard or Reserves?

Have you had any accidents in the past 3 years?
 Yes No
How many?

Do you had any moving violations in the past 3 years?
 Yes No
How many?

Previous Employment

(list up to 3)

Name of Employer:

Name of last supervisor:

Dates of employment:
From:

To:

Salary:
From:

To:

Complete Address:

Phone Number:

Last job title:

Reason for Leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:

May we contact your employer:
 Yes No

(2/3)

Name of Employer:

Name of last supervisor:

Dates of employment:
From:

To:

Salary:
From:

To:

Complete Address:

Phone Number:

Last job title:

Reason for Leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:

May we contact your employer:
 Yes No

(3/3)

Name of Employer:

Name of last supervisor:

Dates of employment:
From:

To:

Salary:
From:

To:

Complete Address:

Phone Number:

Last job title:

Reason for Leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:

May we contact your employer:
 Yes No

Skills:

Typing:

Computer:
 PC Mac Both
Applications (list all that apply):

Other Skills:

Please list 2 references other than relatives and previous employers:

Use this space to add any additional information necessary to describe your full qualifications for the position which you are applying:

In case of emergency, notify:

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 including but not limited to the references listed above, interstate and intrastate criminal background investigations, information concerning my previous employment and pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same to you.
I understand and agree that if an offer of employment is made, I am subject to drug screening and will reimburse Etowah Employment. If drug screening results are positive or if I fail to report to work, I further understand and agree that Employment Innovations Inc dba Etowah Employment promotes a drug free workplace and conducts pre-employment, for cause, and/or random screening.

I understand and agree that in the event I do not report to my assignment. I will be responsible for all costs, including criminal
background investigations, drug screening, and/or safety equipment incurred by Etowah Employment.
The 1995 General Assembly passed House Bill 240 which disqualifies an employee from unemployment benefits if an assignment
ends or the employee leaves and assignment and does not notify the temporary company by the close of the next business day, that they are available for another assignment.

I hereby authorize and give consent, in lieu of signature, to Etowah Employment to use this form and it's information:
 Yes No

Applicant:

Date:

*This form has been designed to strictly comply with State and Federal Fair Employment Practice Laws Prohibiting Employment
Discrimination

Your Email (required)