Job Application

Application

Step 1 of 8

Employment History
Employer #1
Name of Previous Employer
Address of Previous Employer
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Previous Employment
MM slash DD slash YYYY
End Date of Previous Employment
MM slash DD slash YYYY
Salary
Position
Name of Supervisor
Reason for Leaving
Employer #2
Name of Previous Employer
Address of Previous Employer
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Previous Employment
MM slash DD slash YYYY
End Date of Previous Employment
MM slash DD slash YYYY
Salary
Position
Name of Supervisor
Reason for Leaving
Employer #3
Name of Previous Employer
Address of Previous Employer
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Previous Employment
MM slash DD slash YYYY
End Date of Previous Employment
MM slash DD slash YYYY
Salary
Position
Name of Supervisor
Reason for Leaving
Employer #4
Name of Previous Employer
Address of Previous Employer
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Previous Employment
MM slash DD slash YYYY
End Date of Previous Employment
MM slash DD slash YYYY
Salary
Position
Name of Supervisor
Reason for Leaving
Employer #5
Name of Previous Employer
Address of Previous Employer
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Previous Employment
MM slash DD slash YYYY
End Date of Previous Employment
MM slash DD slash YYYY
Salary
Position
Name of Supervisor
Reason for Leaving
Comments regarding gaps or lapses in employment, if possible

Have you ever been discharged from a job or forced or asked to resign?
- Yes
- No
If yes, explain:
Have you ever received any type of discipline, either oral or written, for violation of a prior employer's safety rules?
- Yes
- No
If yes, explain:
Terms and Conditions
I hereby state that the information given by me in this application is true in all respects. I agree that if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at any time. I hereby authorize any former employers to release information pertaining to my work record, my work habits, and my work performance while in their employ.

In making application for employment, I understand that the Facility routinely obtains background reports and/or other information regarding applicants for employment. In connection therewith, a third party or "consumer reporting agency" may provide a report to the Facility which may include information as to my criminal record, if any, driving record, character, general reputation, personal characteristics, mode of living, and other information. I understand that, as a condition of employment, I must complete and sign an "Authorization and Release for the Procurement of a Consumer and/or Investigative Consumer Report" which is attached to this application as "Attachment 1." I understand that I can make a written request for a complete and accurate disclosure of additional information concerning investigations and reports provided by a "consumer reporting agency" as provided under applicable law and/or the Facility's policies.

I understand and agree that any employee handbook which I may receive will not constitute an employment contract, but will be merely a statement of the Facility's current policies which may be changed at the sole discretion of the Facility's management.

I understand that the Facility reserves the right to require its employees to submit to blood tests or urinalysis for alcohol or drug screens, or to allow inspection of bags(including purses or briefcases) or parcels brought into or taken out of the Facility. I understand that refusal to submit to urinalysis, blood test or search, when requested to do so, may result in termination of my employment. I also understand that once a conditional offer of employment has been made, I may be requested to submit to a physical exam which may include an alcohol/drug screen.

I understand and agree that if I am offered employment by the Facility, my employment will be for no definite term and that either I, or the Facility, will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice and that this relationship can only by modified in writing and signed by the Administrator.
Signature

Please enter your name here. This will serve as your digital signature on this employment form.
Date
MM slash DD slash YYYY

Authorization and Release For the Procurement of a Consumer and/or Investigative Consumer Report
As part of its employee selection process, CROWNE MANAGEMENT LLC ("Crowne") routinely obtains consumer reports and/or credit information on applicants and employees applying for promotion. The information contained in these reports may be used to deny an individual employment with Crowne, or to deny an employee a promotion to a particular position.
Authorization to procure a Consumer Report*
- I, the undersigned consumer, do hereby authorize Crowne, by and through an independent contractor (the "Agency") to procure a consumer report and/or investigative consumer report on me.
These above-mentioned reports may include, but are not limited to, employment and education verifications; personal references; personal interview; my personal credit history based on reports from any credit bureau; my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; and/or any other public record.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report prepared on me upon my written request to the Agency that is made within a reasonable time after the date hereof. I also understand that I may request a written summary of my rights under 15 U.S.C. § 1681 et. seq.

I further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose the same to Crowne, by and through the Agency, including, but not limited to, any courthouse, any public agency, any and all law enforcement agencies and any and all credit bureaus, regardless of whether such person, business entity or governmental agency complied the information itself or received it from other sources.

I hereby release Crowne, the Agency, and any and all persons, business entities and governmental agencies, whether public or private, from any and all liability, claims and/or demands, of whatever kind, to me, my heirs or others making such claim or demands on my behalf, for procuring, selling, providing, brokering and/or assisting with the compilation or preparation of the consumer report and/or investigative consumer report hereby authorized.
Name
First Middle Last
Date
MM slash DD slash YYYY
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Current Residence
MM slash DD slash YYYY
Former Address #1
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Former Residence #1
MM slash DD slash YYYY
End Date of Former Residence #1
MM slash DD slash YYYY
Former Address #2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Former Residence #2
MM slash DD slash YYYY
End Date of Former Residence #2
MM slash DD slash YYYY
Daytime Phone Number
Driver's License Number
State of Issuance
Date of Birth
MM slash DD slash YYYY
Gender
Without your date of birth and gender information, we will be unable to properly identify you in the event we find adverse information during the course of our background search.

Job Application

Application

Step 1 of 8

It is the policy of this facility to provide equal employment opportunities without regard to race, color, religion, sex, national origin, disability or any other reason prohibited by law.

Education

Licenses and Certifications

Employment History

Employer #1

Employer #2

Employer #3

Employer #4

Employer #5

Military Service Record

Terms and Conditions

Authorization and Release For the Procurement of a Consumer and/or Investigative Consumer Report