HCSS Employment Application

Application for Employment

Last Name:	First Name:
Address:

City:

State:

Zip:

Phone:

Referred by:

Employment Desired

Position:
Date available:

Salary desired:

Are you employed?
Yes           No If so, may we inquire of your present employer?
Yes           No

Ever applied with us before?
Yes           No Where?
When?

Education History

Name & Location of School Years Attended Graduate? Subjects Studied

Grammar School:

High School:
Yes
No

College:
Yes
No

Trade, Business, or Correspondance School:

Yes
No

General Information

Subjects of Special Study / Research Work or Special Training / Skills:

U.S. Military or Naval Service: Rank:

Former Employers
List below your last four employers, starting with the most recent:

Month & Year Employer Name & Address Salary Position Reason for Leaving

From:
To:

From:
To:

From:
To:

From:
To:

References

Give below the names and phone numbers of three persons not related to you, whom you have known at least one year.

Name Phone Business Years Known

Authorization

"I certify that the facts contained in this application are true and comjplete 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 employement 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 compnay representative.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

By checking this box, you certify that you have read and agree to the above statement:
I agree

Date:

Name & Location of School	Years Attended	Graduate?	Subjects Studied
Grammar School:
High School:		Yes No
College:		Yes No
Trade, Business, or Correspondance School:		Yes No

Month & Year	Employer Name & Address	Salary	Position	Reason for Leaving
From: To:
From: To:
From: To:
From: To:

Give below the names and phone numbers of three persons not related to you, whom you have known at least one year.
Name	Phone	Business	Years Known