Employment Application

Personal Information

Name


	Important Note Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, handicap or veteran status.

Street Address

City

State

Zip

Email Address

Home Phone

Business Phone

Social Security Number

Are you legally eligible for employment in the United States? yes: no:

Position Applied For

Pay Expected

Will you work overtime if asked? yes: no:

When will you be available to begin work?

Have you ever applied for employment with us? yes: no:

If yes: Month and year Location

Apart from absence for religious observance, are you available for full time work? yes: no:

If no: What hours can you work?

Other special training or skills(languages, machine operation, etc.)

Education

School	Name and Location of School	Course of Study	No. of Years Completed	Did You Graduate?	Degree or Diploma
Graduate				yes: no:
College				yes: no:
Business/Trade/ Technical				yes: no:
High School				yes: no:
Elementary				yes: no:

Membership in Professional or Civic Organizations
(Exclude those which may disclose your race, color, religion, or national origin)

Employment
(Please give accurate, complete full-time and part-time employment record.
Start with your present or most recent employer.)

Company Name
Address
Telephone
Name of Supervisor
Employed - (State month and year)	From	To
State Job Title and Describe Your Work
Weekly Pay	Start	Last
Reason for Leaving
If you do not wish us to contact this employer please input a reason not to contact below.

Company Name
Address
Telephone
Name of Supervisor
Employed - (State month and year)	From	To
State Job Title and Describe Your Work
Weekly Pay	Start	Last
Reason for Leaving
If you do not wish us to contact this employer please input a reason not to contact below.

Company Name
Address
Telephone
Name of Supervisor
Employed - (State month and year)	From	To
State Job Title and Describe Your Work
Weekly Pay	Start	Last
Reason for Leaving
If you do not wish us to contact this employer please input a reason not to contact below.

Company Name
Address
Telephone
Name of Supervisor
Employed - (State month and year)	From	To
State Job Title and Describe Your Work
Weekly Pay	Start	Last
Reason for Leaving
If you do not wish us to contact this employer please input a reason not to contact below.

Military

Did you serve in the US Armed Forces? yes: no:

If "Yes", In what branch?

Describe any training received relevant to the position for which you are applying

Driver's License
Do you have a current Louisiana driver's license? yes: no:
License Number	Expiration Date
If "No", Please explain

Ancillary Information
(Please fill out any information below that you feel comfortable providing. The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits discrimination based on age, citizenship, and disability. The laws of most States also prohibit some or all of the above types of discrimination as well as some additional types such as discrimination based upon ancestry, marital status, and sexual preference.)

Number of dependents including yourself?


	Important Note Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, handicap or veteran status.

Are you a Vietnam veteran?

yes: no:

Sex

male: female:

Are you a U.S. Citizen?

yes: no:

Are you 18 years of age?
(If not, employment is subject to age verification)

yes: no:

Marital Status

Single	Engaged	Married
Separated	Divorced	Widowed
Date of Marriage

What was your previous Address?

How long at present address?

How long at previous address?

Have you ever been bonded? yes: no:

If "Yes", with what employers?

Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by a court? yes: no:

If "Yes", describe in full

Provide dates you attended school	From	To
Elementary
High School
College
Other (give names and dates)

State the names of relatives and friends working for us, other than your spouse

Background check
	By checking this box I assert that A&H service company is authorized to do a background check to verify the information provided on this form.

Drug test
	By checking this box I assent to a drug test should a position be offered to me. A drug test is done on every new hire at A&H service company.

Signature

By checking this box I assert that the information provided in this Application for Employment is true, correct and complete. If you employ me, any misstatement or omission of fact on this application may result in my dismissal.

By checking this box, I also understand that acceptance of an offer of employment creates no obligation upon you, the employer, to continue to employ me in the future.