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Job Application Form

Identifying Information
First Name*
Last Name*
Cell Phone*
Email*
Street Address*
City*
State*
ZIP Code*
County
General Information
Are you prevented from lawfully becoming employed in this country because of visa or immigration status? (Proof of citizenship or immigration status will be required upon employment)*
- Yes
- No
If you are hired and are under 18, can you furnish a work permit?*
- Yes
- No
Are you physically and mentally able to perform the essential duties of the job for which you are applying, either with or without reasonable accommodation?*
- Yes
- No
Are you on layoff and subject to recall by another employer?*
- Yes
- No
Do your work and educational records appear under a different name?*
- Yes
- No
If “yes,” please provide the relevant name(s)
Have you been convicted of a crime at any time? Are there any pending criminal charges against you?*
- Yes
- No
If you answered “yes” to either question, please explain
* Conviction of a crime, and/or a pending criminal charge, will not necessarily be a bar to employment. The Company will consider the relationship between the conviction and the position sought, as well as other factors.
Have you previously applied to, or been employed with, the Company?*
- Yes
- No
If “yes,” please provide the relevant date(s)
Are you acquainted with, or related to, any current Company employee?
- Yes
- No
If “yes,” please provide the employee’s name
Are you currently employed?*
- Yes
- No
May we contact your present employer?*
- Yes
- No
If “no,” please explain
Availability
On what date would you be available to begin working?*
MM slash DD slash YYYY
Check all applicable
- Full Time
- Part Time
PLEASE SPECIFY THE HOURS YOU ARE AVAILABLE FOR WORK:
EXAMPLE: 8:00AM – 5:00PM
Mon – FRI

: From

To

AM/PM
Sat -Sun

: From

To

AM/PM
Desired Hourly Rate/Yearly Salary*
Education
High School
School Name
Did you graduate?
- Yes
- No
Year of graduation
MM slash DD slash YYYY
Business / Vocational
School Name
Did you graduate?
- Yes
- No
Diploma / Degree
College / University
School Name
Did you graduate?
- Yes
- No
Diploma / Degree
Employment Experience
List your previous jobs during the last 10 years in consecutive order, starting with your present or last job. Exclude organization names that indicate race, color, religion, sex, height, weight, national origin, age, marital status, veteran status, genetic traits, disability, or any other factors prohibited by law.
Employer Name
Job Title
Phone
Location
Phone
Dates Employed
MM slash DD slash YYYY

From
Dates Employed
MM slash DD slash YYYY

To
Hourly Rate / Salary
Starting
Hourly Rate / Salary
Final
Work Performed
Reason For Leaving
May we contact this employer
- Yes
- No
Add another Employment reference?
- YES
Employment Experience #2
Employer Name
Job Title
Phone
Location
Phone
Dates Employed
MM slash DD slash YYYY

From
Dates Employed
MM slash DD slash YYYY

To
Hourly Rate / Salary
Starting
Hourly Rate / Salary
Final
Work Performed
Reason For Leaving
May we contact this employer
- Yes
- No
Would you like to add another source of employment experience?
- Yes
Employment Experience #3
Employer Name
Job Title
Phone
Location
Phone
Dates Employed
MM slash DD slash YYYY

From
Dates Employed
MM slash DD slash YYYY

To
Hourly Rate / Salary
Starting
Hourly Rate / Salary
Final
Work Performed
Reason For Leaving
May we contact this employer
- Yes
- No
Additional Information
References: Please identify three references who are not related to you
References 1
Occupation
Years Known
Phone Number
References 2
Occupation
Years Known
Phone Number
References 3
Occupation
Years Known
Phone Number
Additional Information
Please set forth any additional information that would assist us in making our hiring decision
1. I acknowledge that every question on this application is material. I further understand that any false or inaccurate information provided by me on this application may result in my rejection as an applicant and/or my termination from employment.

2. I have been given and read a separate Disclosure Notice and Authorization Regarding Consumer and Investigative Reports. I hereby authorize an investigation of my education, employment, driving, criminal and credit histories, including related statements contained in this application. Further, I authorize the Company to consult with, and receive and use information from, all third parties with whom or which I have been associated concerning those histories and/or any other aspect of my qualifications, or with any third parties who may have information bearing thereon. I release all third parties who provide information to the Company, with or without notice to me, from any and all liability for providing information regarding my histories or qualifications to the Company or its agents. I waive any and all notice(s) I would otherwise be entitled to receive by law in connection with reference checks. I further authorize the Company to forward to, and release the Company from all liability for forwarding, any other entity to which I may apply for employment, any information concerning me and/or my histories or qualifications as the Company has at the time of my application for employment or hereafter acquires.

3. I understand I am applying for an “at will” employment position, which means either the Company or I may terminate my employment at any time, with or without cause, and with or without notice. This is my entire agreement with the Company on the subject of the duration of my proposed employment. The at-will nature of my employment may be changed only by a subsequent agreement in writing signed by the President of the Company, addressed specifically to me, and entitled “Amended Employment Agreement.” I acknowledge that the Company may, in its sole discretion, modify my assigned work hours, duties, place of work, compensation, and other terms of employment.

4. I agree to abide by the Company’s policies and procedures as may be amended from time to time. Further, I agree to execute other agreements required by the Company, consistent with the Company’s business objectives.

5. State law shall apply to this application and my employment, regardless of choice-of-law principles. In the event that one or more provisions of this application are declared void or unenforceable, such provision shall be severed and the balance of the provisions shall remain in effect.

6. I understand this application will be considered current for 90 days and that a new application must be completed for further consideration after 90 days.

7. In consideration of my prospective employment and/or, if hired, my employment, I agree to file any claim arising out of or in any way related to my application for employment, employment and/or cessation of employment within one hundred-eighty (180) days after the claim(s) arise(s), or within the applicable statutory limitations period(s) provided by law, whichever occurs first, and my failure to do so shall act as a bar to any claim that I may have. I waive any longer statutory limitations period to the contrary.

I hereby acknowledge that I have read the above statement, understand and agree to same, and certify as true and accurate all information I have provided herein.
Signature of applicant (Full Name)*
Date*
MM slash DD slash YYYY
Disclosure notice and authorization regarding consumer and investigative reports

IMPORTANT: Please read and consider carefully before signing.

In accordance with the Fair Credit Reporting Act (“FCRA”), Home First Certified and its affiliates (the “Company”) may obtain consumer reports and/or investigative consumer reports regarding your character, employment history, general reputation, criminal record, education, qualifications, motor vehicle record, references, mode of living, credit characteristics (including credit standing, credit capacity and credit worthiness), and/or other personal characteristics in connection with your potential or actual employment with the Company. Pursuant to this disclosure, and your signed authorization below, the Company may obtain consumer reports and/or investigative consumer reports at any time during the employment application process or, as permitted by law, during employment with the Company. The fact that the Company may obtain a consumer and/or investigative consumer report on you does not mean, and should not be construed to mean, that the Company has otherwise decided to offer you employment.

Whenever it is required by the FCRA, before any adverse action is taken by the Company based in whole or part on information contained in a consumer report or investigative consumer report, you will receive a copy of the report, the name, address and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA. You are entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of which you are the subject upon your written request to the Company, if such is made within a reasonable time after the date hereof. You may also obtain a written summary of your rights under 12 U.S.C. § 1681 et seq.

Authorization

I hereby authorize, without reservation, the Company and/or its affiliates to obtain consumer reports and/or investigative consumer reports concerning me at any time for employment-related purposes. I understand that such consumer reports and investigative consumer reports may contain information regarding my character, employment history, general reputation, criminal record, education, qualifications, motor vehicle record, references, mode of living, credit characteristics (including credit standing, credit capacity and credit worthiness), or other personal characteristics. I recognize that, as permitted by law, the Company has the right to obtain additional consumer reports in the future regarding me as to any employment-related matter.

I further authorize all persons and entities to release all written and verbal information about me to the Company and/or its agents, any consumer reporting agency or any other entity, for use by the Company for employment-related purposes. I hereby agree to hold harmless from liability and responsibility, and to release, the Company and those affiliated with it from any and all liability, claims and/or demands of whatever kind regarding the compilation or preparation of the consumer report and/or investigative consumer report hereby authorized, and from decisions made concerning my application for or continuation of employment based upon the results of the background investigation.

I authorize the use of the identifying information provided below in conducting the background investigation and/or compiling a consumer report or investigative consumer report. I understand that refusal to permit a background investigation or failure of the background investigation may result in the Company denying my application for employment or immediately terminating my employment.

I hereby authorize that a photocopy of this authorization may be construed as an original.

My signature below indicates that I have read and acknowledged the “Disclosure Notice” above and that I have freely given my authorization in accord with the foregoing.
Signature of applicant (Full Name)*
Date*
MM slash DD slash YYYY
Address
Have you ever been convicted of a crime
- Yes
- No
Please note that you are not required to disclose any arrest or any conviction that has been erased or expunged pursuant to court order, that pertains to a finding of juvenile delinquency, or that has been dismissed, nolle prossed or for which you have received an absolute pardon.
Date Of Conviction
MM slash DD slash YYYY
City, State where convicted
Crime
Full Name at time of conviction

Job Application Form

Identifying Information

General Information

Availability

PLEASE SPECIFY THE HOURS YOU ARE AVAILABLE FOR WORK:

Education

Employment Experience

Employment Experience #2

Employment Experience #3

Additional Information

Disclosure notice and authorization regarding consumer and investigative reports

IMPORTANT: Please read and consider carefully before signing.

Authorization

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