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Social Security No.
Date You Can Start
If so, May we Inquire of
your present Employer?
Ever Applied to
This company Before?
Name & Location Of School
Did You Graduate?
Trade, Business or Correspondence School
Subjects of special study/research work of special training/skills
U.S. military or naval service
(List below last four employers, starting with last one first)
Date Month And Year
Name & Address of Employer
Reason For Leaving
Give below the names of three persons not related to you when you have known at least one year.
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 from 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 pro-habited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
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