Employment - Moline Heating and AC (Air Conditioning) services by Doug's Heating and Air Conditioning

Personal Information

Name (last name first)
Present Address	City	State	Zip
Permanent Address	City	State	Zip
Phone #
Referred By

Employment Desired

Position
Date You Can Start
Salary Desired
Are You Employed	Yes No	May we contact your present employer?	Yes No
Ever applied to this company before? Yes No
	Where? When?

Education History

Name & Location of School	Years Attended	Did You Graduate?	Subjects Studied

Grammar School

High School

College

Trade, Business or CorrespondenceSchool

General Information

Subjects of special study/research work or special training/skills


U.S Military or Naval Service		Rank

Former Employers (List below last four employers, starting with last one first)

Date	Name & Address of employer	Salary	Position	Reason for leaving

References - Give below the names of three persons not related to you, whom you have known at least one year.

Name	Address	Business	Years known

Authorization

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreements contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”

Date I agree with the above terms