Employment Application - Lead Installer/Technician

Personal Information

Name (Last)

First

(Middle)

Home Address

City

State

Zip Code

Home Phone

Cell Phone

Business Phone

May we contact you at work?

Position Applying For

Date Available

Are you interested in (check all that apply)

Are you willing to relocate?

Are you 18 years or older?

How did you hear about us?

If "Other" please elaborate:

Education

Type of School

Name and Location of School

Degree/Area of Study

# Years Attended

Graduated

High School

Name

City

Address

State

Zip Code

College

Name

City

Address

State

Zip Code

Graduate School

Name

City

Address

State

Zip Code

Other

Name

City

Address

State

Zip Code

U.S. Military Service

Branch of Service

Technical Specialization

Rank Attained

Legal

Are you legally authorized to work in the United States? (Identity and employment eligibility of all new hires will be verified as required by the Immigration Reform and Control Acts of 1986.)

Were you ever discharged by any company? If yes, give name of company(ies):

Have you ever been convicted of or plead guilty to (including a plea of nolo contendere) a misdemeanor at any time within the past 5 years? If yes, please explain in full:

Have you been convicted of or plead guilty to (including a plea of nolo contendere) a felony (you are not obligated to disclose sealed, erased or expunged records of conviction(s) or records of arrests or criminal charges which did not result in a conviction)? If yes, please explain offense and final disposition:

(A conviction will not necessarily disqualify an applicant from employment.)

Federal, State, and local laws prohibit discrimination based on race, color, sex, religion, affectional or sexual orientation, national origin, ancestry, age, physical or mentaldisability that does not affect ability to perform essential job function(s) with or without reasonable accommodation, or any other protected status not listed in thisstatement. Your application will be considered in full accord with applicable Federal, State, and local requirements.

Employment History

List employment starting with your most recent position. You may include a description of verified work performed on a volunteer basis. Is any additional information relative to a different name necessary to check your work record? If yes, explain.

Job Title #1

Start Date

End Date

Company

Supervisor's Name

Phone Number

City

State

Zip

Duties:

Reason for Leaving

Starting Salary

Ending Salary

Job Title #2

Start Date

End Date

Company

Supervisor's Name

Phone Number

City

State

Zip

Duties:

Reason for Leaving

Starting Salary

Ending Salary

Job Title #3

Start Date

End Date

Company

Supervisor's Name

Phone Number

City

State

Zip

Duties:

Reason for Leaving

Starting Salary

Ending Salary

Job Title #4

Start Date

End Date

Company

Supervisor's Name

Phone Number

City

State

Zip

Duties:

Reason for Leaving

Starting Salary

Ending Salary

Job Title #5

Start Date

End Date

Company

Supervisor's Name

Phone Number

City

State

Zip

Duties:

Reason for Leaving

Starting Salary

Ending Salary

References

Name

Address

Work Phone Number

Title

Years Known

Please Read Carefully

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate dismissal. I understand, also, that I am required to abide by all rules and regulations of Immedia LLC.

I understand and agree that if employed, employment will be “AT WILL.” That is, either I or the employer may end the employment relationship at any time, for any reason, or for no reason.

I understand that receipt of this application does not imply employment and that this application and/or any other documents are not contracts of employment. I understand that I am applying for work with Immedia LLC. If hired, Immedia LLC will be my only employer.

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