NAME (LAST NAME FIRST) SOCIAL SECURITY NO. PRESENT ADDRESS CITY STATE ZIP CODE PERMANENT ADDRESS CITY STATE ZIP CODE PHONE HOW DID YOU HEAR THAT HARRIETT'S iS HIRING? EMPLOYMENT DESIRED YOUR EMAIL ADDRESS *
POSITION DATE YOU CAN START SALARY DESIRED ARE YOU CURRENTLY EMPLOYED? IF SO, MAY WE INQUIRE YOUR PRESENT EMPLOYER? EVER APPLIED THIS COMPANY BEFORE? WHERE? WHEN?
NAME AND LOCATION OF SCHOOL YEARS ATTENDED DID YOU GRADUATE? SUBJECTS STUDIED GRAMMAR SCHOOL GRAMMAR SCHOOL NAME GRAMMER YEARS ATTENDED GRAMMER GRADUATE? GRAMMAR SUBJECTS STUDIED HIGH SCHOOL HIGH SCHOOL NAME HIGH SCHOOL YEARS ATTENDED HIGH SCHOOL GRADUATE? HIGH SCHOOL SUBJECTS STUDIED COLLEGE COLLEGE NAME COLLEGE YEARS ATTENDED COLLEGE GRADUATE? COLLEGE SUBJECTS STUDIED TRADE, BUSINESS AND CROSSPONDENCE SCHOOL TRADE SCHOOL NAME TRADE SCHOOL YEARS ATTENDED TRADE SCHOOL GRADUATE? TRADE SCHOOL SUBJECTS STUDIED
SUBJECTS OF SPECIAL STUDY/RESEARCH WORK OR SPECIAL TRAINING SKILLS:
SUBJECTS OF SPECIAL STUDY/RESEARCH WORK OR SPECIAL TRAINING SKILLS: SUBJECTS OF SPECIAL STUDY/RESEARCH WORK OR SPECIAL TRAINING SKILLS:
COMPUTER PROGRAMS AND SKILLS
COMPUTER PROGRAMS AND SKILLS COMPUTER PROGRAMS AND SKILLS US MILITARY OR NAVAL SERVICE RANK
FORMER EMPLOYER (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST)
DATE MONTH AND YEAR NAME AND ADDRESS OF EMPLOYER SALARY POSITION REASON OF LEAVING
EMPLOYER 1 NAME EMPLOYER 1 SALARY EMPLOYER 1 POSITION EMPLOYER 1 REASON FOR LEAVING
EMPLOYER 2 NAME EMPLOYER 2 SALARY EMPLOYER 2 POSITION EMPLOYER 2 REASON FOR LEAVING
EMPLOYER 3 NAME EMPLOYER 3 SALARY EMPLOYER 3 POSITION EMPLOYER 3 REASON FOR LEAVING
THREE BUSINESS REFERENCES
BUSINESS NAME TELEPHONE NO. CONTACT PERSON YEARS KNOWN BUSINESS REFERENCE 1 BUSINESS REFERENCE 1 PHONE BUSINESS REFERENCE 1 CONTACT BUSINESS REFERENCE 1 YEARS KNOWN BUSINESS REFERENCE 2 BUSINESS REFERENCE 2 PHONE BUSINESS REFERENCE 2 CONTACT BUSINESS REFERENCE 2 YEARS KNOWN BUSINESS REFERENCE 3 BUSINESS REFERENCE 3 PHONE BUSINESS REFERENCE 3 CONTACT BUSINESS REFERENCE 3 YEARS KNOWN
NAME/RELATIONSHIP CITY/STATE TELEPHONE # EMERGENCY CONTACT 1 EMERGENCY CONTACT 1 CITY/STATE EMERGENCY CONTACT 1 TELEPHONE EMERGENCY CONTACT 2 EMERGENCY CONTACT 2 CITY/STATE EMERGENCY CONTACT 2 TELEPHONE EMERGENCY CONTACT 3 EMERGENCY CONTACT 3 CITY/STATE EMERGENCY CONTACT 3 TELEPHONE Attach Resume
"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 and 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 Americans with Disabilities Act (ADA) and other relevant federal and state laws." DATE
Background Check for Purposes of Employment At Harriett’s Energy Solutions or Harriett’s Water Conditioning
Print Name Please
I authorize Harriett's Human Resources to conduct an appropriate background check for the determination of my eligibility to occupy a position of trust within the Harriett’s organization. I authorize persons who provide information
relevant to this check to disclose it to Harriett’s Energy Solutions Human Resources or a designated manager. I relieve all persons from liability in providing this information given in good faith and honest disclosure.
The above pertains to:
1. References you listed on Harriett’s employee application and your resume, if one has been submitted.
2. Running a current Motor Vehicle Abstract if applying for a position that will entail the possibility of you driving a Harriett’s vehicle.
Birth Date Driver's License # Issuing State
3. I give my consent to a physical examination by a physician and to have a drug and alcohol test done and a criminal check
once hired, as a prerequisite for working at Harriett’s Energy Solutions or Harriett’s Water Conditioning. I agree that, as an operator of a Harriett’s vehicle, I will also be subject to random drug tests.
For reasons of privacy, this information would be privy to the Human Resource person, the manager of the department you are hired for, and the president of the company, Mr. Bob Harriett, only.
for applying at Harriett’s! Thank you Signature of Prospective Employee