Breakroom Choices Career Application

General Information

Name: First Last

Email

If other, please describe:

Emergency Contact Name: First Last

State and License number:

If so, where and when?

If so, explain:

If no, please explain:

If so, where?

Educational Background

High School:

City:

If no, GED or years completed:

If yes, year graduated:

College:

Years attended:

If so, what?

Vocational training/ Other:

What skills do you have that you believe would make you a good employee?

Previous Employment

List most recent employers first.

Company #1:

Address:

Job Title:

Reason for leaving:

Dates of employment:

Company #2:

Address:

Job Title:

Reason for leaving:

Dates of employment:

Company #3:

Address:

Job Title:

Reason for leaving:

Dates of employment:

Company #4:

Address

Job Title:

Reason for leaving:

Dates of employment:

U.S. Military Service:

Branch:

Rank:

References

Give three references other than relatives.

Name:

Address:

Name:

Address:

Name:

Address:

Attach Resume

Authorization

I certify the information contained in this application is true and complete to the best of my knowledge. If information is found to be falsified, I understand this can be grounds for dismissal.

If an employment relationship is established I will have the right to terminate my employment at any time and the company will have a similar right. If hired, there is a 90 day probationary period. I authorize checking all statements contained in this application including references in order to give information, personal or otherwise, and release the company from all liability for any damage that may result from use of such information.

If I am hired to drive a company vehicle, I understand that any offer of employment is contingent upon acceptance of my driver's license Motor Vehicle Report by the company's insurance carrier.

I understand that any offer of employment is contingent upon obtaining a negative drug screen result within 72 hours of employment, a negative TB test, and an acceptable background check to which the company shall be the sole determiner. Should I terminate my employment with Breakroom Choices in less than 90 day of my hire date, I agree to have the cost of the pre-employment drug screening,TB test, and criminal background check deducted from my final check.

Breakroom Choices does not discriminate in hiring or employment on the basis of race, religion, national origin, gender, age, veteran status, marital status, or disability. No question on this application is intended to secure information to be used for such discrimination.

Applicant's Signature:

Wufoo

General Information

Educational Background

Previous Employment

U.S. Military Service:

References

Authorization