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Today's Date*

It is the policy of Techniquex to provide Equal Employment Opportunities to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, physical or mental handicap or veteran status.

Position Desired

Desired Salary

Personal Information

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth*

Phone*

Email*

Social Security*

Driver's License*

Issuing State*

State

Birthplace*

City State / Province / Region

Are you a U.S. Citizen*

Yes

Do you have a clean driving record?*

Yes

Do you have a valid driver's license?*

Yes

Do you have dependable transportation?*

Yes

Do you own the transportation?

Yes

Techniquex requires background check – can you pass?*

Yes

Techniquex requires a drug test – can you pass?*

Yes

Do you have any issues with taking a physical?*

Yes

Do you have any reason to believe you won't pass a physical?

Yes

Are you looking for a career?*

Yes

Did you serve in the U.S. Military?*

Yes

Branch of Service

Rank at time of discharge

I served from

What is your available start date?*

Employment History

Employer

Your position

Employment from (date)

Supervisors Name

First Last

Supervisors Phone

Supervisors Email

Reasons for leaving

Employer

Your position

Employment from (date)

Supervisors Name

First Last

Supervisors Phone

Supervisors Email

Reasons for leaving

Employer

Your position

Employment from (date)

Supervisors Name

First Last

Supervisors Phone

Supervisors Email

Reasons for leaving

Add a fourth employer

Yes

Employer

Your position

Employment from (date)

Supervisors Name

First Last

Supervisors Phone

Supervisors Email

Reasons for leaving

Education

High School

School Name

Address

Street Address City State ZIP Code

Did you graduate?

Yes

Attended from

College or University

School Name

Address

Street Address City State ZIP Code

Did you graduate?

Yes

Attended from

Degree

Major

References

Name

First Last

Phone

Business/Occupation

Years known

Name

First Last

Phone

Business/Occupation

Years known

Name

First Last

Phone

Business/Occupation

Years known

Release

I hereby authorize Techniquex and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas:

Verification of Social Security Number, current and previous residences, employment history including all personnel files, education, character references, credit history and reports, criminal history records from any criminal justice agency in any or all federal, state county jurisdictions, birth records, motor vehicle records to include traffic citations and registration and any other public records.

I authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I understand that I must provide my date of birth to adequately complete said screening, and acknowledge that my date of birth will not affect any hiring decisions. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me, to furnish bearer with any and all information in their possession regarding me in connection with an application for employment. This authorization and consent shall be valid in original, fax, or copy form. Techniquex operates a drug-free work place. Drug testing will be done on all applicants for employment. The applicant must have a clean drug screening to be considered for hire.

I hereby release Techniquex, and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization and request to relapse. You may contact me as indicated below, I understand that a copy of this authorization may be given to me at any time, provided I request it in writing. Information on this application and results of the background investigation will be maintained in confidence in accordance with company hiring practices. I hereby certify that my answers and assertions set forth in this application are true and complete to the best of my knowledge. If I am employed, I understand that any false statements on this application shall be considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of my prior educational and employment history.

Furthermore I understand that if I am hired, employment with this company is “at will,” which means that either the company or I can terminate my employment for any reason not prohibited by state or federal law.

Signature*

Name*

First Last

Date*