CHAMPSCARPET.COM


Applicant Information
Full Name:		Position Applied For:
Telephone #:	E-Mail:	Highest Level of Education Completed:
Are you legally eligible for employment in the United States? Yes No
Do you have a drivers license? Yes No
Have you been convicted of a crime in the last seven (7) years? Yes No If yes, please explain (briefly) in the space below:


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Personal History
Have you ever been disciplined at work? (This includes written warnings, formal letters of counseling, reprimands, suspensions, reductions in pay, reassignments, or demotions.)			Yes No
Have you ever been fired, released from probation, or asked to resign from any place of employment?			Yes No
Have you ever been involved in a physical/verbal altercation with a supervisor, co-worker, or customer?			Yes No
Have you ever quit without giving notice?			Yes No
Have you ever resigned in lieu of termination?			Yes No
Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual orientation harassment, etc.) by a co-worker, superior, subordinate or customer?			Yes No
Have you ever been the subject of a written complaint at work?			Yes No
Have you ever been counseled at work due to lateness or absences?			Yes No
Have you ever received an unsatisfactory performance review?			Yes No
Have you ever sold, released, or given away legally confidential information?			Yes No
Have you ever called in sick when you were neither sick nor caring for a sick family member?			Yes No
In the past three years, have you missed days or been late to work due to drug or alcohol consumption?			Yes No
In the past three years, has your work performance ever been affected by your use of alcohol or drugs?			Yes No
In the past three years, have you been warned by an employer about your drinking or drug habits and their impact on your performance?			Yes No
If you answered yes to any of the questions above, please explain (briefly) in the space below:


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Previous Employment
Please list the employer you worked for the longest
Company:	Address:	Phone:	Supervisor Name:
Job Title:	Duties Performed:
Start Date - End Date:	Reason for Leaving:		May we contact for a reference? Yes No


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Professional References
Please list two (2) professional references
Name:	Address & Telephone #:	Company:	Relationship:


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Additional Information
How did you hear about us?
Tell us (briefly) why we should hire you:


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Applicant Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States of America and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (1) eliminate me from further consideration for employment, or (2) may result in my immediate discharge from the employer’s service, whenever it is discovered. I certify that I have read, fully understand, and accept all terms of the above Applicant Statement.


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