Employment Opportunities Employment Full Name* Email Address* Current Address* Current City* Current State/Province* Current Zip* Permanent Address* Permanent City* Permanent State/Province* Permanent Zip* Referred By* Phone Number* Salary Desired* Position* Date You Can Start*12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 20132014201520162017201820192020202120222023 Are You Currently Employed?* What is your availability?* Do You Have Reliable Transportation?* Do You Smoke?* Former Employers (Please provide Employer Name, Address, Salary, Position and Reason for Leaving)* References (Please provide Name, Address, Phone and Years Known):* AUTHORIZATION"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 Americans with Disabilities Act (ADA) and other relevant federal and state laws." I have read this agreement in its entirety and agree to its authorization.