Application for Employment

Employment Application

Name: *
Date: *
Address: *
City: *
State: *
Zip: *
Cell Phone: *
Home Phone: *
E-mail Address *
Type of work desired: *
Salary Desired: *
Date Available: *
If hired, can you provide documents required to establish your eligibility to work in the U.S.? * yes
no
Are you 16 years of age or older? * yes
no
Have you ever worked for Midwestern Services, Inc.? * yes
no
How were you referred to Midwestern Services, Inc.? *
Have you ever been convicted of, or pled guilty or no contest to, a crime other than a minor traffic violation? * yes
no

If yes, please explain in detail in the below and include the date of final disposition of the case and the nature of the offense. This information will not necessarily disqualify you from employment but false or misleading information will. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.

Name & Address of School: *
Course of Study: *
Number of Years Completed: *
Degree/Diploma: *
College or Technical School
Name & Address of School:
Course of Study:
Number of years completed:
Degree/Diploma:
Other Schooling or Training
Name & Address of School:
Course of Study:
Number of years completed:
Degree/Diploma:
Do you have any military experience? * yes
no
If so, what branch of service?
Rank or type of service:
Describe job-related training or experience:
Please list your most recent Employers
Employer: *
Telephone: *
Address: *
Position or title: *
Supervisor: *
Start Date: *
Date Left: *
Beginning Salary: *
Ending Salary: *
Duties: *
Reason for Leaving: *
Employer: *
Telephone: *
Address: *
Position Title: *
Supervisor: *
Start Date: *
Date Left: *
Beginning Salary: *
Ending Salary: *
Duties: *
Reason for Leaving: *
Employer: *
Telephone: *
Address: *
Position Title: *
Supervisor: *
Start Date: *
Date Left: *
Beginning Salary: *
Ending Salary: *
Duties: *
Reason for Leaving: *
Please list 3 work related references. (Do not include relatives)
Name: *
Occupation: *
Years Known: *
Contact Info: *
Name: *
Occupation: *
Years Known: *
Contact Info: *
Name: *
Occupation: *
Years Known: *
Contact Info: *

STATEMENT (Please read this statement carefully before signing this application):

I understand that employment with Midwestern Services, Inc. is at-will, meaning that I or Midwestern Services, Inc. may terminate my employment at any time, or for any reason consistent with applicable state or federal law.

I understand that Midwestern Services, Inc. requires the successful completion of a drug and/or alcohol test as a condition of employment.

Please read and digitally sign the authorization for background to complete your application process.

Authorization for Background Information

I authorize Midwestern Services, Inc and its agents to obtain and review, now and during my employment, my past employment, education, and activities, and to request and receive any information concerning me, including but not limited to, criminal history, and public records from any persons, entities, schools, companies, corporations, partnerships, associations, state agencies, departments of labor, law enforcement agencies, licensing agencies, and from my previous employers.I further release, discharge, and hold harmless Midwestern Services, Inc., its agents, any persons, law enforcement agencies, schools, or personal/business entities and their respective officers, directors, employees, representatives and agents of any kind from any and all claims, liability, damages and responsibility of whatever kind or nature, arising out of or in connection with any act or omission in any such investigation or compliance with this authorization and request to release information, or any attempt to comply with it. This paragraph applies to any negligence, sole negligence, comparative negligence, concurrent negligence, error, or omission.I have voluntarily signed this release to assist in the evaluation of my employment qualifications.I agree that if any investigation at any time reveals that I provided false information to, or omitted information from Midwestern Services, Inc., then disciplinary action may occur including termination of my consulting assignment and/or employment with Midwestern Services, Inc., without liability.Midwestern Services, Inc. is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability, genetic information, or any other characteristic protected by law.

Last Name: *
First Name: *
Middle Name: *
Maiden Name: *
Street Address: *
City: *
State: *
Zip: *
Social Security Number: *
Drivers License Number: *
State: *
Digital Signature: (Please type your full name) *
Today's Date: *
Date of Birth: (MM/DD/Year) *

I understand this application will be active for a period of no less than 365 days; after that time, if I wish to be considered for employment, I must submit a new application. I certify that all the statements in this completed application are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to hire.

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