Applicant Information
Last Name: First: M.I.: Date:
Street Address: Apartment/Unit#:
City: State: ZIP:
Phone: Email Address:
Emergency Contact Name: Emergency Contact Phone:
Date Available: Desired Salary:
Position Applied For:
Are you a citizen of the United States? Yes No If no, are you authorized to work in the U.S.? Yes No
Have you ever worked for this company? Yes No If so, when?
Have you ever been convicted of a felony? Yes No If yes, explain
Are you 18 years old or older? Yes No
Are you willing to work rotating shifts? Yes No
Are you willing to work overnight shifts? Yes No
Are you willing to work weekends? Yes No
Do you possess a valid U.S. driver's license?
Yes No 		State: Number: Expires:
Do you have any relatives working for Omni-Serv? Yes No Relative's name & relationship to you:
Are you currently employed? Yes No If yes, explain:
Who referred you to this company?
Education
High School: Address:
From: To: Did you graduate? Yes No Degree:
College: Address:
From: To: Did you graduate? Yes No Degree:
Other: Address:
From: To: Did you graduate? Yes No Degree:
Please list any areas of specialty training, study, or skills:
References
Please list three professional references
Full Name: Relationship:
Company: Phone:
Address:
Full Name: Relationship:
Company: Phone:
Address:
Full Name: Relationship:
Company: Phone:
Address:
Previous Employment
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary $ Ending Salary $
Responsibilities:
From: To: Reason for Leaving:
Many we contact your previous supervisor for a reference? Yes No
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary $ Ending Salary $
Responsibilities:
From: To: Reason for Leaving:
Many we contact your previous supervisor for a reference? Yes No
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary $ Ending Salary $
Responsibilities:
From: To: Reason for Leaving:
Many we contact your previous supervisor for a reference? Yes No
Military Service
Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:
Disclaimer and Signature

By submitting this form, I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I authorize investigation of all statements contained herin 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 the utilizing 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.
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