Application Application for Employment PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER Personal InformationName* First Middle Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* General InformationWhat position are you applying for? Type Full Time Part Time Are you seeking a permanent position? Yes No Expected Starting Wage: When are you available to start work? Are you willing to work overtime? Yes No Are you at least 18 years old? Yes No Are you willing to do after hours service calls? Yes No Are you a U.S. citizen? Yes No If no, can you verify that you are authorized to work in the U.S.? Yes No Do you have a valid driver's license? Yes No Do you have reliable daily transportation to get to work? Yes No What languages so you speak, read, or write fluently? Have you ever been convicted of a felony? Yes No (Note: Conviction will not necessarily disqualify applicant)If so, please explain:Employment HistoryEmployment HistoryEmployer name and address:Position title/duties, skills:Starting Pay:Ending Pay:Supervisor:Phone#:Start Date:End Date:Reason for leaving: Skills and QualificationsList any special skills, abilities, certificates, licenses, or honors that should be considered: EducationHigh SchoolHigh School:LocationFromToDid you graduate?DegreeCollegeCollege:LocationFromToDid you graduate?DegreeOtherOther:LocationFromToDid you graduate?DegreeMilitary ServiceAre you a military veteran? Yes No Branch: From MM slash DD slash YYYY To MM slash DD slash YYYY Rank at discharge: Type of discharge: Duty / specialized training: References List three personal references who are not related to you:ReferencesNameAddressPhoneOccupationYears Known Certification and Acknowledgement I certify that the information provided herein is true and correct to the best of my knowledge. I understand that, if employed, falsified statements on this Application for Employment form will be considered grounds for termination. I understand that I may be required to supply my birth certificate or other proof of authorization to work in the United States, consent to a drug test, and/or sign a conflict of interest agreement and abide by its terms. I authorize the company to thoroughly investigate my work experience and any other matters related to my suitability for employment. I further authorize my former employers to disclose to the company any and all information they may have concerning my previous employment. In addition, I hereby release Harper Special Services, my former employers, and all other persons from any and all claims, demands, or liabilities arising out of, or in any way related to such disclosure. I acknowledge that, if employed, both Harper Special Services and I have the right to terminate the employment relationship at any time, with or without cause or advance notice. This employment at will relationship will remain in effect throughout my employment with Harper Special Services and may not be modified by any oral implied agreement.Applicant's Signature and DateNameThis field is for validation purposes and should be left unchanged.