Job Application Form

First Name

Middle Name

Last Name

Present address

How long at present address

TRN No

Telephone

Date of birth

Position applied for

Salary desired

How many hours can you work weekly?

Can you work nights?

Employment desiredFull TimePart TimeFull or Part Time

When available for work?

High School

Location

Years

Major/Degree

College Name

Location

Years

Major/Degree

Bus. or Trade School

Location

Years

Major/Degree

Professional School

Location

Years

Major/Degree

HAVE YOU EVER BEEN CONVICTED OF A CRIME?YESNO

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

Please list two references other than relatives or previous employers. One of which must be a Justice of the peace.

Name

Name

Position

Position

Company

Company

Address

Address

Telephone

Telephone

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY

Name

Telephone

Address

Relationship

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give a firm name.

Name of employer Address Name of the last supervisor Employment dates Pay or salary City, Parish Phone number

Name of the last supervisor

Employment dates

Pay or salary

Last Job Title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company.

May we contact your present employer?YesNo

Did you complete this application yourselfYesNo

If not, who did?

PERSONAL HEALTH DATA:

What is your present state of health?

Date of last medical examination

Work days missed for illness during the past 2 years of work?

Date of last illness

How is your vision?

How is your hearing?

Do you have any disability or handicap?YesNo

Do you suffer from headaches?YesNo

Cardiovascular disease?YesNo

Hypertension?YesNo

Sinus or allergies?YesNo

Diabetes?YesNo

Back/Spinal Problems?YesNo

Asthma?YesNo

Circulation Problems?YesNo

Are you Pregnant Or Suspect that you might be Pregnant?YesNo

---

In exchange for the consideration of my job application by MENDEZ FUTURE GEN SOLUTIONS LIMITED (hereinafter called “the Company”), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of MENDEZ FUTURE GEN SOLUTIONS LIMITED, or otherwise to change in any respect the employment-at- will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and MENDEZ FUTURE GEN SOLUTIONS LIMITED may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise its benefits, policies, and procedures and such changes may include a reduction in benefits. I authorize the investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract. I also understand that (1) the Company has a drug and alcohol policy that provides for pre- employment testing as well as testing after employment; (2) consent to and compliance with such Personal Health Data 4 policy is a condition of my employment, and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party. I hereby authorize any person, educational institution, or company that I have listed as a reference on my employment application to disclose in good faith any information they may have regarding my qualifications and fitness for employment. I will hold MENDEZ FUTURE GEN SOLUTIONS LIMITED, any former employers, educational institutions, and any other persons giving references free of liability for the exchange of this information and any other reasonable and necessary information incident to the employment process.

---

Signature

Date

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Submit Application