PERSONAL INFORMATION

Today's Date:

 First Name:  
 Last Name:  
 Address:  
 City:  
 State:     Zip:    

Phone Number (required):

 High School
 School Name and Location

 Years Completed:   Did you graduate?  Yes  No

 Subjects studied

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 College
 School Name and Location

 Years Completed:   Did you graduate?  Yes  No

 Subjects studied and degrees received

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 Trade, Business or Correspondence School
 School Name and Location

 Years Completed:   Did you graduate?  Yes  No

 Subjects studied and degrees received

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 GENERAL

 Subjects of Special Study or Research Work

 Job Related Skills (typing, driver's license, etc.)

 Activities Other Than Religious (Civic, Athletic, etc.)
 Exclude organizations, the name or character of which indicates the race, sex, color, or national origin of its members.

 

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 FORMER EMPLOYERS
 List below your last three employers, starting with the most recent first.

 Start Date:

 End Date:

 Employer Name:

 Employer Address:  

 Employer City, State & Zip: 

 Wage/Salary (upon leaving):

 Position:

 Reason for leaving:

*********

 Start Date:

 End Date:

 Employer Name:

 Employer Address:  

 Employer City, State & Zip: 

 Wage/Salary (upon leaving):

 Position:

 Reason for leaving:

*******

 Start Date:

 End Date:

 Employer Name:

 Employer Address:  

 Employer City, State & Zip: 

 Wage/Salary (upon leaving):

 Position:

 Reason for leaving:

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 REFERENCES
 List below three persons not related to you; whom you have known for at least one year.

 Name:

 Phone Number:

 Position:

 Years Acquainted:

 **********

 Name:

 Phone Number:

 Position:

 Years Acquainted:

 *********

 Name:

 Phone Number:

 Position:

 Years Acquainted:

 *********

 If you are to be hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identify and employment eligibility.  You cannot be hired if you cannot comply with these requirements.

AUTHORIZATION

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge.  I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the REACH, Inc.

I understand that any employment is conditioned on a background check.  I authorize REACH, Inc. to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to REACH, Inc., without giving me prior notice of such disclosure.  In addition, I release REACH, Inc, any former employers and all references listed above from any and all claims, demands, or liabilities arising out of or related to such investigation or disclosure.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract.  I further understand and agree that if I am hired, my employment will be "at will" and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or REACH, Inc.  No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon REACH, Inc. unless made in writing.

If I am offered employment I agree to submit to a medical examination and drug test before starting work.  If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by REACH, Inc. and as permitted by law.  I consent to such examinations and tests, and I request that the examining doctor disclose to REACH, Inc. the results of the examination, which results shall remain confidential and segregated from my personal file.  I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug tests, and if I am hired a condition of my employment will be that I abide by the Company's Drug and Alcohol Policy.

I understand that filling out this form does not indicate there is a position open and does not obligate REACH, Inc. to hire.  If hired, I agree to abide by REACH, Inc work rules, policies, and procedures.  REACH, Inc. retains the right to revise its policies or procedures, in whole or in part, at any time.

By typing your name below, you are accepting and agreeing to the conditions listed above.