Tom’s Installation Company, Inc.

An Equal Opportunity Employer

Application for Employment

Type or Print Application Information

Personal Information

Name: (Last, First, Middle)	Social Security #	Date of Birth
Street & Mailing Address	Phone (Include Area Code):	Alt. Phone
Are you a US Citizen? [ ] Yes [ ] No List Nationality:	Driver’s License #	State & Date of Issue
Marital Status [ } Married [ ] Single [ ] Divorced	No of Dependents:	E-mail:

Education & Training

High School	Date of Graduation:	Course of Study:
Vocational/Trade School:	Date of Completion:	Course of Study:
College	Number of Quarters/Credits:	Course of Study:
Other Training:	Date of Completion:	Course of Study:

Military Service

Branch of Service

Dates of Service

Type of Discharge

Special Training:

Have you ever applied for a US Security Clearance?

[ } Yes [ ] No

Was it granted?

[ ] Yes [ ] No

Check Level:

[ ] Top Secret [ ] Other

[ ] Confidential [ ] Secret

List Special Recognitions:

Employment History - Begin with most recent Employer

Name of Employer	Hire Date: Term Date:	Position or Title	Starting Pay: Ending:	[ ] Hrly [ ] Salary
Address of Employer:	Reason for Termination:	Name of Supervisor	Phone (Include Area Code)	Contact Employer?
Name of Employer	Hire Date: Term Date:	Position or Title	Starting Pay: Ending:	[ ] Hrly [ ] Salary
Address of Employer:	Reason for Termination:	Name of Supervisor	Phone (Include Area Code)	Contact Employer?
Name of Employer	Hire Date: Term Date:	Position or Title	Starting Pay: Ending:	[ ] Hrly [ ] Salary
Address of Employer:	Reason for Termination:	Name of Supervisor	Phone (Include Area Code)	Contact Employer?

List at Least Two Personal References

Name:

Address:

Phone (Include Area Code):

Employer:

Name:

Address:

Phone (Include Area Code):

Employer:

Please Read Before Signing

Have you been convicted of a felony? [ ] Yes [ ] No (If yes, provide details on the reverse side of this application including dates.)

Tom’s Installation Company, Inc. is an Equal Opportunity Employer and is interested and concerned for the safety and welfare of their employees and customers. By signing this application you acknowledge that you, as an applicant, may be asked to submit to a drug/alcohol urine test as a condition of employment. All results of such tests shall remain confidential, but shall be released to and become the property of Tom’s Installation Company, Inc. I certify that the information provided by me in this application is true and correct.

______________________________________________________ ___________________________

Cursive Signature of Applicant Date

(If you are unable to sign, insert your legal mark with a witness)

Distribution: One copy to Employee, one copy to Supervisor and original to Personnel File.

CONSENT FOR DRUG/ALCOHOL TESTING

If you are offered and accept employment with Tom’s Installation Company, Inc., in the interest of safety for all concerned, you may be required to take a urine test for drug and/or alcohol use.

I, ___________________________________, have been fully informed of the reason for this urine test for drug and/or alcohol (I understand what I am being tested for), the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will be forwarded to my potential employer and become part of my record.

If this test is positive, and for this reason I am not hired, I understand that I will be given the opportunity to explain the results of this test.

I hereby authorize these test results to be released to Tom’s Installation Company, Inc.

_______________________________________ Date: ______________

Signature:

______________________________________ Date: ______________

Witness: