Reliant Employment Services, LTD |
8590 County Road 12 1/2 |
(432) 617-4251 |
Pampa, Texas 79065 |
In compliance with Federal and State equal employment opportunity laws, qualified
applicants are considered for all positions without regard to race, color, religion,
sex, national origin, age, marital status or non-job related disability. |
|
Date of this Appication:
|
Position you are applying for: |
First Name:
|
Last Name:
|
SSN:
|
Date of Birth (Required for Commercial Drivers Only):
|
Driver's License Class:
|
Driver's License No:
|
License State:
|
Expires:
|
Endorsements: (mark all that apply)
None
P-Passenger
T-Double/triple trailer
N-Tank Vehicles
H-Hazardous Materials
X-Tank Vehicle & Hazardous Materials
Restrictions:
|
Current Address:
|
City:
|
State:
|
Zip:
|
Email Address:
|
Telephone:
|
Alternate:
|
How long at current address?:
Years:
Months:
|
If you have not lived at the above address for the past three years or longer, please
list former addresses for the previous three years: |
Address: |
City: |
State: |
Zip: |
How long? Years:
Months: |
|
Address: |
City: |
State: |
Zip: |
How long? Years:
Months: |
|
Address: |
City: |
State: |
Zip: |
How long? Years:
Months: |
|
If hired, do you have the
legal right to work in the United States?: |
Can you provide proof of age?: |
Have you worked for this company before?: |
If yes, where?: |
Dates: From
To
 |
Rate of pay: |
Position: |
Reason for Leaving: |
|
Are you employed now?:
|
If yes, may we contact
your present employer?: |
If no, how long since
leaving your last employment?: |
Who referred you?: |
Rate of pay you would expect:
per (hour, day, week or month):
|
|
Is there any reason you might be unable to perform the functions of the job for
which you have applied?:(Note: if in doubt,
please ask for a description of the complete duties you would be expected to perform
in regard to the position you are applying for). If yes, explain if you wish: |
|
Have you ever been convicted of a felony or misdemeanor charge?:If yes, please list (Note: Convictions will not necessarily disqualify applicant): |
|
EDUCATION |
Highest grade completed:
College: |
Name of last school attended:
|
Year:
|
City:
|
State:
|
Please list any areas of special study that would be applicable to the position
you are applying for: |
|
MILITARY STATUS |
Have you served in the US Armed Forces?: |
If yes, Branch: |
Date of Entry:
 |
Rank at time of discharge: |
Date of Discharge:
 |
(In New Jersey fill in this line until hired) Draft Status:Reserve Status: |
Disclosure and Authorization
to Employees and Prospective Employees
to Obtain Information |
**This must be filled out by all applicants** |
The applicant agrees to furnish such additional
information and complete such examinations
as may be required to complete his/her employment file. |
|
This application for employment does not obligate Reliant Employment Services, Ltd.
to employ this applicant. In the event this applicant should be hired, the
employment will be on a probationary period during which time he may be discharged
without recourse. |
|
In consideration for you furnishing such information, I specifically waive any confidentiality
relationship or privacy position which may exist between us and completely release you from any responsibility or liability for damages which may occur as the result
of the disclosre of truthful information. |
|
A photocopy or any other copy of this instrument bearing my signature shall be equally
and legally valid as the original. |
|
In connection with evaluating me for employment, promotion, reassignment or retention
as an employee, Reliant Employment Services, Ltd., may obtain a consumer report
containing information regarding claims and lawsuits,
driving history, criminal history, education and/or credit. |
|
I understand I have the right to request information regarding the nature and scope of the
investigation requested. |
|
The Fair Credit Reporting Act gives me specific rights in dealing with consumer
reporting agencies. I understand I will be given a summary of these rights with this
document.
I acknowledge receipt of this disclosure and my rights under the Fair Credit Reporting
Act. |
|
By my electronic signature below, I certify that this application was completed
by me, and that all entries on it and information in it are true and complete to
the best of my knowledge. I do hereby authorize Reliant Holdings Ltd., Reliant
Employment Services Ltd., Reliant Transportation Ltd. and their affiliates to perform
a background check on my background, including the procurement of the following
reports and information:
- Examination of documents and record keeping required by federal immigration laws;
- Verification of my employment history for the past five (5) years;
- Verification of my education records for the highest degree I have received;
- Check of court records during the past seven (7) years in all counties in which
I have resided for the last seven (7) years;
- Review of Department of Motor Vehicle records;
- Examination of the federal Food and Drug Administration Debarment List, the federal
Food and Drug Administration Restricted List, and the federal Department of Health
and Human Services - Office of Inspector General Exclusion List;
- Credit check where my job assignment involves financial or money-related functions;
- Check of records of criminal convictions;
- Check of arrest records during the past seven (7) years.
- Access the FMCSA Pre-Employment Screening Program(PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years
|
|
Name:
|
Social Security No:
|
|