Wufoo
DICKSON: JOB APPLICATION
GENERAL INFO
First Name
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Middle Name
Last Name
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Phone Number
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Once your application has been received, we will contact you for your social security #
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Yes, I will provide
Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
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Afghanistan
Åland Islands
Albania
Algeria
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Angola
Anguilla
Antarctica
Antigua & Barbuda
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Benin
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Bolivia
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Bouvet Island
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Caribbean Netherlands
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Chad
Chile
China
Christmas Island
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Colombia
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Mali
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Mayotte
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Montenegro
Montserrat
Morocco
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Myanmar (Burma)
Namibia
Nauru
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Netherlands
New Caledonia
Nicaragua
Niger
Nigeria
Niue
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North Korea
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Norway
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Panama
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Poland
Portugal
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Sri Lanka
St. Barthélemy
St. Helena
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St. Lucia
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Sudan
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Switzerland
Syria
Taiwan
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Tanzania
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U.S. Outlying Islands
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Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Email
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Emergency Contact Name
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Emergency Contact Phone #
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Are you at least 18 years old, a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation)
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Have you ever been convicted of or plead guilty to a crime?
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Have you been charged with a crime with the outcome yet to be determined?
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If yes for either question, please describe conditions.
Are you looking for full-time or part-time and what hours are you available?
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On which of the following are you available to work overtime? Select all that apply
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Weekdays
Saturdays
Sundays
Have you been previously employed by the company? If yes, give date(s)
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Are you presently employed?
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May we contact your present employer?
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May we contact your past employer?
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Date you are available to start:
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What position are you applying for?
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Please list applicable skills or training, as well as other special skills, licenses or certifications that you would like us to know about:
EDUCATION
High School: Name & Location
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Grade Level Completed
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College: Name & Location
Years Completed
Area of Study / Degree
Please list any scholastic honors received and offices held in school.
EMPLOYMENT HISTORY
1. Employer Name & Location
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From - To
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Job Title
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Duties
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Reason for Leaving
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Phone #
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Supervisor
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Pay Rate
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2. Employer Name & Location
From - To
Job Title
Duties
Reason for Leaving
Phone #
Supervisor
Pay Rate
3. Employer Name & Location
From - To
Job Title
Duties
Reason for Leaving
Phone #
Supervisor
Pay Rate
Have you ever been discharged or asked to resign from any position?
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If yes, please state the employer, supervisor and dates of employment:
Are you currently or do you intend to be engaged in another business, employed by another employer or working as an independent contractor?
If yes, do you intend to continue this activity if offered employment?
If yes, please describe the circumstances of your employment or other outside work:
Are you on layoff, inactive status, or on leave of absence from any other employment?
If yes, do you anticipate returning to work at such other employment?
MILITARY SERVICE
From - To
Duties
References
List three personal references, not related to you, who have known you for more than one year.
REFERENCE 1 - INCLUDE THE FOLLOWING
1. First and Last Name
2. Years known
3. City, State
4. Home phone #
5. Cell phone #
6. Email address
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REFERENCE 2 - INCLUDE THE FOLLOWING
1. First and Last Name
2. Years known
3. City, State
4. Home phone #
5. Cell phone #
6. Email address
REFERENCE 3 - INCLUDE THE FOLLOWING
1. First and Last Name
2. Years known
3. City, State
4. Home phone #
5. Cell phone #
6. Email address
Employee Acknowledgement
Please read and accept before clicking submit:
I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application. I understand that it shall be ground for immediate dismissal if any of the information provided herein is found to be incomplete and untrue.
I authorize my previous employer, schools, or persons listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of employment with the company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees.
In compliance with the Immigrations Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of the approved documents that are required.
I agree to submit to urinalysis and/or other tests as shall be determined by the Company in the selection process of applicants for employment for the purpose of determining the drug content thereof.
I agree to take a drug and alcohol test if I have an at work injury while employed by the Company.
I agree to hold harmless the Company and its agents from any liability arising in whole or in part out of the collection of specimens, testing, and use of the information from said testing in connection with the Company’s consideration of my employment application.
I understand that employment at the company is "at will," which means that either I or the company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis.
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I hereby acknowledge that I have read and understand the above statements.
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