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Application

Application for Employment

PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER

Personal Information

Name(Required)
Address(Required)

General Information

Type
Are you seeking a permanent position?
Are you willing to work overtime?
Are you at least 18 years old?
Are you willing to do after hours service calls?
Are you a U.S. citizen?
If no, can you verify that you are authorized to work in the U.S.?
Do you have a valid driver's license?
Do you have reliable daily transportation to get to work?
Have you ever been convicted of a felony?
(Note: Conviction will not necessarily disqualify applicant)

Employment History

Employment History
Employer name and address:
Position title/duties, skills:
Starting Pay:
Ending Pay:
Supervisor:
Phone#:
Start Date:
End Date:
Reason for leaving:
 

Skills and Qualifications

List any special skills, abilities, certificates, licenses, or honors that should be considered:

Education

High School
High School:
Location
From
To
Did you graduate?
Degree
College
College:
Location
From
To
Did you graduate?
Degree
Other
Other:
Location
From
To
Did you graduate?
Degree

Military Service

Are you a military veteran?
MM slash DD slash YYYY
MM slash DD slash YYYY

References

List three personal references who are not related to you:
References
Name
Address
Phone
Occupation
Years 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.

This field is for validation purposes and should be left unchanged.

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Harper Special Services
5102 Ogeechee Rd., Suite B
Savannah GA, 31405

Phone: 912-235-5671
Hours: Open 24 hours

Payment Method: We accept all major credit cards and checks, as well as work with all insurance companies.

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