East Polk LLC
Employment Application
 PERSONAL
Last Name: First Name:
MI:
 SSN:
Address:
 City:
 State:
 Zip Code:
 Day Phone: (required) (digits only)
 Cell Phone: (digits only)
 Email: (required)
Have you been a resident of Florida for five (5) years or more? Yes    No
  If not, please list previous address
 
  Hours available
  Days available Monday Tuesday Wednesday Thursday Friday Saturday Sunday
  Position applied for?
 
 Salary Desired?
  How were you referred to company?
 
  Are your applying for?
Full Time    Part Time    Regular    Temporary
  Relatives or friends employed by company? Yes    No

  Relatives or friends Name?

  Date available for employment?  Date:
  Have you ever been employed by this company?
  Yes    No
When?  
  Reason for leaving?
 
  Emergency contact?
  Emergency phone number?
  Relationship?
  Are you a U.S. citizen or an alien legally authorized to work in the United States? Yes    No
  Have you ever been convicted of a felony? Yes    No
  If convicted of a crime, please explain?
 
 
 Driving
  Do you have a Driver's License? Yes    No
  What is your means of transportation?
Driver's License Number State of issue Type of License Expiration Date
  Have you had any accidents in the past three years? Yes    No
  If so, how may?
 
  Have you had any moving violations in the past three years? Yes    No
  If so, how may?
 
 
 EDUCATION
School Name & Address of School Course of Study Years
Completed		 Did You
Graduate		 List Diploma
or Degree
 High
 College
 Other
 Area of specialization or major interest?
 
  Typing? Yes    No
  Typing: approx wpm?  
  Computer Skills? Beginner    Intermediate    Advanced
  CADD? Yes    No
  CNC?   Yes    No
  Other Technology Skills?
 
  List business or industrial equipment operated?
 
 
 Military
  Have you ever been in the armed forces?
Yes    No
  Honorably discharged?
Yes    No
  Are you current in the Guard or Reserves?
Yes    No
  Specialty?
 
  Date Entered?
  		  Date Discharged?
 
 
 EMPLOYMENT HISTORY (Most Recent Jobs First)  
 Employer Name:
  Dates:  To
 Address:
 Immediate Supervisor:
  Salary?
  Reason for leaving?
  Job title:
  Job duties:
 
 
 Employer Name:
  Dates:   To
 Address:
  Immediate Supervisor:
  Salary?
   Reason for leaving?
  Job title:
  Job duties:
 
 
 Employer Name:
  Dates:   To
 Address:
 Immediate Supervisor:
  Salary?
   Reason for leaving?
  Job title:
  Job duties:
 
 
 Employer Name:
  Dates:  To
 Address:
 Immediate Supervisor:
  Salary?
  Reason for leaving?
  Job title:
  		  Job duties:
 
  State if you do not want us to contact any of the above listed former employers and the reason you do not want each contacted.
 Can we run a detailed employment check, including but not limited to a check with your previous employers?
Yes    No

Please type your full name here to authorize reference check
 
 REFERENCES
 (Employment Contact)
 Name and Relationship:
  Title:
 Company Name & Address:
  Phone:
 
 Name and Relationship:
  Title:
 Company Name & Address:
  Phone:
 
 Name and Relationship:
  Title:
 Company Name & Address:
  Phone:
 

  READ THIS SECTION PRIOR TO SUBMITING THIS APPLICATION


 "I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED. MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME.

 IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE. AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY'S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. I UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT'S PRESIDENT, AND THEN ONLY WHEN IN WRONG AND SIGNED BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.
 
 To apply for this position, place your initials in the box below and click the "Submit Application" button to indicate that you understand and accept these terms. Your application will then be submitted. If you are the successful candidate, you will be asked to sign a copy of this application.

 Your Initials:
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