Untitled Document

Employment Application

EMPLOYMENT APPLICATION FORM:

City Express is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including age, sex, color, race, creed, national origin, religious persuasion, marital status, political belief, or disability that does not prohibit performance of essential job functions. City Express acknowledges that the Employee Polygraph Protection Act of 1988 prohibits employers from using lie detector tests either for pre-employment screening or during the course of employment as a term or condition of employment.

Date:
Your First Name:
Your Last Name:
Your Middle Initial*:
Present Address Line 1:
Present Address Line 2:
City:
State:
ZIP Code:
Permanent Address Line 1:
Permanent Address Line 2:
City:
State:
ZIP Code:
Social Security Number:
How long at this address: (years/months)
Are you at least 18 years of age:	yes no

Home Phone:
Alternative Mobile Phone:
E-mail Address:
Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver's license, birth certificate, green card, etc.) within 3 days of being hired. Failure to submit such proof within the required time, shall result in immediate employment termination.
Do you have any relatives who are presently (or have formerly been), employed by City Express? If yes, please list them below.	yes no
Is there any information we would need about your name or use of another name, for us to be able to check your work record? Please specify:
How did you learn about us?
If you heard about us from someone else (a referral), please let us know the name of the person who told you about us:
Have you ever been convicted of a felony?	yes no If yes, please explain:
EDUCATIONAL HISTORY:
Hiigh School:
College:
Technical Training:
Other:
EMPLOYMENT RECORD: Please provide us with commercial business references that you have worked with. You should include companies that you have had an affiliation within the past 5 years:

Name of Business:
Position Held:
Address of Company:
Month and Year Affiliation Began:
Month and Year Affiliation Ended:
Manager/Supervisor:
Phone Number:	(Include area code)
Wage/Salaryr:
Reason for leaving:
Business Reference 2:
Name of Business:
Position Held:
Address of Company:
Month and Year Affiliation Began:
Month and Year Affiliation Ended:
Manager/Supervisor:
Phone Number:	(Include area code)
Wage/Salaryr:
Reason for leaving:
Business Reference 3:
Name of Business:
Position Held:
Address of Company:
Month and Year Affiliation Began:
Month and Year Affiliation Ended:
Manager/Supervisor:
Phone Number:	(Include area code)
Wage/Salaryr:
Reason for leaving:
NOTE: We will contact all of the employers listed on this application unless you specifically exclude them below. Please list any employers you do NOT want us to contact and the reason for the exclusion.
Employer's Name:
Reason:
Employer's Name:
Reason:
REFERENCES Please do not include relatives or former employers.
First and Last Name:
Years Known:
Nature of Relationship:
Occupation:
Telephone Number:	(Include area code)
REFERENCE 2:
First and Last Name:
Years Known:
Nature of Relationship:
Occupation:
Telephone Number:	(Include area code)
REFERENCE 3:
First and Last Name:
Years Known:
Nature of Relationship:
Occupation:
Telephone Number:	(Include area code)
WORK AVAILABILITY:
When would you be available to start?
Are you flexible to work evenings and/or weekends?	yes no
Can you work overtime without prior notice?	yes no
Are you familiar with a data entry keyboard?	yes no
Are you looking for a career or just a fill-in position?	CAREER Fill- in
Are you flexible to change your work hours if needed?	yes no
Nature of Relationship:
Occupation:
Telephone Number:	(Include area code)
SALARY/HOURLY RATE REQUIREMENTS:
Is there any salary requirement?	yes no
If yes, please list:	$ per

ACKNOWLEDGEMENT AND AUTHORIZATION:
I acknowledge that the information contained herein is correct to the best of my knowledge, and that any misrepresentation of material fact may be cause of termination of my contract. I am providing City Express with authorization to check my references and background information, and I provide permission to call or write or otherwise communicate with persons or companies listed in my profile above, and to investige using public or other sources as deemed necessary by City Express to verify such information.

$ per