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Employment Application Untitled Page Water Treatment Chemical Supplier, Ice Melt Distributor, Pool Chemical Supplier

Please complete the following for Employment with Buckman's Inc.

Personal Information
Name (Last, First, Middle): ,   
Email Address:
Present Address:
Street:
City:  State:
Zip:
Permanent Address:
Street:
City:  State:  
Zip:
Phone Number:
Are you 18 years or older?
 
Have you ever been convicted of felony criminal activity?
If you answered yes to the above question, explain:
Are you willing to undergo a Criminal Record Check?

(Based on the findings of the Criminal Record Check in relation to the relevant job requirements, you may or may not be considered for the position for which you are applying.)
Employment Desired
Position:
Date You Can Start: Salary Desired:
Are you employed now?
If so, may we inquire of your present employer?
Ever applied to this company before?
Where?
When?

Education Name and Location of School NO. Years Attended Did you graduate? Subjects Studied
Grammar School
High School
College
Trade, Business or Correspondence School
* The Age Discrimination Employment Act of 1967 prohibits discrimination on the basis of age with respect to individiuals who are at least 40 but less than 70 years of age.
General
Subjects of Special Study or Research Work
U.S. Military or Naval Service:
Rank:
Present Membership in National Guard or Reserves:
Former Employers
(List below last four employers starting with last one first.)
Month/Year Name and Address of Employer Salary Position
Reason for Leaving
Reason for Leaving
Reason for Leaving
Reason for Leaving
References
Give the names of three persons not related to you, whom you have known at least one year.
Name Address Business Years Aquainted
Physical Record
Do you have any physical limitations that preclude you from performing any work for which you are being considered?
If yes, what can be done to accomodate your limitation?

Please describe:
In case of emergency:
Name:
Address:
Phone:

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. the references listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definate period and may, regardless of the date of payment of my wages and salary, be terminated for any time without prior notice.