First Name * Last Name * Street Address * City * State * Phone # * E-Mail * Date of Birth * Driver License Number Is Your Drivers License Valid? If no, why? If hired, can you provide proof that you are legally able to work in the U.S.? - Yes No Have you ever been convicted of a criminal offense (felony or misdemeanor)? Note: An affirmative answer will not necessarily result in disqualification for employment. If yes, please state nature of offense(s), date(s), city, state and disposition of the offense: EMPLOYMENT: Position Desired Salary Desired When are you available to begin work?
Are you able to perform the essential functions of the job for which you are applying? Our days are fasted paced. There is very little time to sit or down time. There is a lot of bending, on your knees, stretching and moving small furniture. Note: We comply with the Americans with Disabilities Act and will consider reasonable accommodation measures that may be necessary for eligible applicants to perform essential functions: _ Yes No EDUCATION: Name of High School or Trade School # of Years Completed
Please account for all employment within the last five years. 1) Most Recent Company Name Company Address Supervisor ’s Telephone Number Dates Employed Salary Duties Reason for Leaving May we contact this employer? - Yes No 2) Company Name Company Address Supervisor ’s Telephone Number Dates Employed Salary Duties Reason for Leaving May we contact this employer? - Yes No 3) Company Name Company Address Supervisor ’s Telephone Number Dates Employed Salary Duties Reason for Leaving May we contact this employer? - Yes No
(Check each numbered item as read)
2) I understand that C.M.A. is committed to maintaining a drug and alcohol free work place. Accordingly, I may be subject to a pre-employment blood test, urinalysis or other drug/alcohol screening. I further understand that if employed, I may be subject to such a drug and alcohol screening if C.M.A. has reasonable suspicion to believe that I am under the influence of a drug or alcohol. My consent to submit to such a test is required as a condition of employment and my refusal to consent shall result in a refusal to hire or, if already employed, termination.
3) I understand and agree that any misrepresentation or omission of facts in this application will be justification for refusal or termination of employment, regardless of the time elapsed before discovery.
4) I understand and agree that the employment for which I am applying for is at-will and such employment may be terminated at any time with or without cause, without prior notice, by either myself or . There will be no agreement, express or implied between and me for any specific period of employment, nor for continuing or long term employment, unless made in writing, signed by an authorized representative of .
5) I have placed my signature in the space provided below only after I have completed the entire application to the best of my ability and have carefully read the statements above. Applicant Name Date