| Last Name
|
First Name
|
Middle Name
|
| Street Address
|
City
|
State
|
| Main Phone
|
Cell Phone
|
Zip Code
|
| Type of Employment
|
Date Available
|
Driver's License Number
|
| General
Questions |
| Do you have any objection to working overtime
if necessary? |
|
| Have you ever been employed by Lloyds before?
|
|
| Do you have proof of legal employment authorization
and identity? |
|
| If you are under 18, can you furnish a work
permit if it is required? |
|
| Can you meet the attendance requirements? |
|
| How were you referred to us? |
|
| Have you ever been convicted of a crime in the
last 7 years? |
|
| If yes, please explain (a conviction will not
automatically bar employment): |
|
Employment
History
Please
provide all employment information for your past four employers
starting with the most recent.
|
| Current
or most recent employment |
| Employer Name:
|
Employer Address:
|
Employer Phone:
|
| Position Held:
|
Date Started:
|
Date Left:
|
| Immediate Supervisor & Title:
|
Final Salary:
|
Reason for leaving:
|
Job Summary
|
| Second
most recent employment |
| Employer Name:
|
Employer Address:
|
Employer Phone:
|
| Position Held:
|
Date Started:
|
Date Left:
|
| Immediate Supervisor & Title:
|
Final Salary:
|
Reason for leaving:
|
Job Summary
|
| Third
most recent employment |
| Employer Name:
|
Employer Address:
|
Employer Phone:
|
| Position Held:
|
Date Started:
|
Date Left:
|
| Immediate Supervisor & Title:
|
Final Salary:
|
Reason for leaving:
|
Job Summary
|
| Fourth
most recent employment |
| Employer Name:
|
Employer Address:
|
Employer Phone:
|
| Position Held:
|
Date Started:
|
Date Left:
|
| Immediate Supervisor & Title:
|
Final Salary:
|
Reason for leaving:
|
Job Summary
|
Skills
and Qualifications
Summarize any training, skills, licenses,
and/or certificates that may qualify you as being able to
perform job-related functions in the position for which you
are applying. |
Skills:
|
Qualifications:
|
Certifications:
|
| Educational
History |
| High School Name:
|
High School City / State
|
Did you graduate?
|
| College Name:
|
Course of Study:
|
Degree:
|
| Technical School Name:
|
Course of Study:
|
Degree or Diploma:
|
| Other:
|
| References |
| Name:
|
Contact Info:
|
Relation:
|
| Name:
|
Contact Info:
|
Relation:
|
| Name:
|
Contact Info:
|
Relation:
|
| |
|
|
I hereby authorize the potential employer to contact, obtain,
and verify the accuracy of information contained in this
application from all previous employers, educational institutions,
and references. I also hereby release from liability the
potential employer and its representatives for seeking,
gathering, and using such information to make employment
decisions and all other persons or organizations for providing
such information.
I understand that any misrepresentation or material omission
made by me on this application will be sufficient cause
for cancellation of this application or immediate termination
of employment if I am employed, whenever it may be discovered.
If I am employed, I understand that I am free to resign
at any time, with or without cause and without prior notice,
and the employer reserves the same right to terminate my
employment at any time, with or without cause and without
prior notice, except as may be required by law. This application
does not constitute an agreement or contract for employment
for any specified period or definite duration. I understand
that no representative of the employer, other than an authorized
officer, has the authority to make any assurances to the
contrary. I further understand that any such assurances
must be in writing and signed by an authorized officer.
I understand that it is the policy not to refuse to hire
or otherwise discriminate against a qualified individual
with a disability because of that persons need for a reasonable
accommodation as required by the ADA.
I also understand that if I am employed, I will be required
to provide satisfactory proof of identity and legal work
authorization within three days of being hired. Failure
to submit such proof within the required time shall result
in immediate termination of employment.
I represent and warrant that I have read and fully understand
the foregoing, and that I seek employment under these conditions.
Applicant Initials:
Date:
|
