Employment Application - La Boit Specialty Vehicles, Inc.

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EMPLOYMENT APPLICATION

Personal Information
First Name*
Last Name*
Social Security No.*
Home Address*
City*
State*
Zip*
Home Telephone
Business Telephone
May we contact you at work?
- Yes
- No
Position Applying for:
Date Available:
MM slash DD slash YYYY
How were you referred to La Boit, Inc.?
If you are under 18 years of age, please state your date of birth:
MM slash DD slash YYYY
Education

High School - Name and Address of School
High School Name
High School Address
High School City
High School State
High School Zip
Degree/Area of Study
Number of years attended
Graduated (check one)*
- Yes
- No
College - Name and Address of School
College Name
College Address
College City
College State
College Zip
College - Degree/Area of Study
College - Number of years attended
Graduated (check one)*
- Yes
- No
Graduate School - Name and Address of School
Graduate School Name
Graduate School Address
Graduate School City
Graduate School State
Graduate School Zip
Graduate School - Degree/Area of Study
Graduate School - Number of years attended
Graduated (check one)*
- Yes
- No
Other - Name and Address of School
Other - School Name
Other - School Address
Other - City
Other - State
Other - Zip
Other - Degree/Area of Study
Other - Number of years attended
Graduated (check one)*
- Yes
- No
U.S. Military Service
Branch of Service
Technical Specialization
Rank Attained
Legal
Are you a U.S. citizen or do you have a legal right & necessary documents to work in the U.S.?
- Yes
- No
(Identity and employment eligibility of all new hires will be verified as required by the Immigration Reform and Control Act of 1986).
Were you ever discharged by any company?
- Yes
- No
If so, give name of company(ies)
Reason for discharge?
Have you ever been convicted of a crime other than a minor traffic violation?
- Yes
- No
If yes, please explain offense and final disposition:
Employment History

List employment starting with your most recent position. Account for any time during this period that you were unemployed by stating the nature of your activities.
May we contact your present employer?
- Yes
- No
May we contact your past employer?
- Yes
- No
Please indicate if you were employed under a different name.
Employer
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Name and Address of Employer

Name and Address of Employer
Address of Employer
City of Employer
State of Employer
Job title
Supervisor
Starting Salary or Wages
Final Salary or Wages
List Major Duties
Reason for Leaving
Employer
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Name and Address of Employer

Name and Address of Employer
Address of Employer
City of Employer
State of Employer
Job title
Supervisor
Starting Salary or Wages
Final Salary or Wages
List Major Duties
Reason for Leaving
Employer
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Name and Address of Employer

Name and Address of Employer
Address of Employer
City of Employer
State of Employer
Job title
Supervisor
Starting Salary or Wages
Final Salary or Wages
List Major Duties
Reason for Leaving
Have you ever worked at La Boit, Inc.?
- Yes
- No
References

Business references: (do not list relatives) (please indicate if you were employed under a different name)
Reference Name
Reference Address
Work Phone #
Title
Years Known
Reference Name
Reference Address
Work Phone #
Title
Years Known
Reference Name
Reference Address
Work Phone #
Title
Years Known
Please read carefully

In submitting this application for employment, I understand that an investigation may be made whereby information is obtained regarding my character, previous employment, general reputation, educational background, credit record and/or criminal history. I authorize anyone possessing this information to furnish it to La Boit, Inc. and/or a 3rd party company upon request and I release anyone so authorized, La Boit, Inc. and any 3rd party company from all liability and damages whatsoever in furnishing, obtaining or using said information.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate dismissal. I understand also, that I am required to abide by all rules and regulations of La Boit, Inc. I understand and agree that if employed, the employment will be ‘at will’. That is, either I or La Boit, Inc. may end the employment relationships at any time, for any reason, or for no reason. I understand that receipt of this application by La Boit, Inc. does not imply employment and that this application and/or any other La Boit, Inc. documents are not contracts of employment.
APPLICANT’S SIGNATURE*
DATE SIGNED*

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mobile-healthcare-association

700 Cross Pointe Rd.
Gahanna, Ohio 43230
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   Toll Free: 800-776-9984
  Local: 614-231-7640
   Fax: 614-231-7680

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