Application for Employment
Former Employers (List below last three employers, starting with the most recent)
References (List professional references whom we may contact)
Special Purpose Questions
Do not answer ANY of the questions in this box unless the employer has checked the box preceding a question, thereby indication that the information is required for a bona fide occupational qualification, or dictated by national security laws, or is needed for other legally permissible reasons.
You will not be denied employment solely because of a conviction record, unlessthe offense is related to the job for which you have applied.
Are you able to perform each of the following job function with or without an accomodation?
"I certify that the facts contained in this application are true and complete 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 employment 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 company representative.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the American with Disabilities Act (ADA) and other relevant federal and state laws.”