EMERGENCY CONTACT

In the case of an emergency, please contact:

NAME :

RELATIONSHIP:

DAYTIME TELEPHONE:

EVENING TELEPHONE:

EMPLOYMENT HISTORY

Provide the following information of your three (3) past employers, assignments or volunteer activities, starting with the most recent.

Job 1

From:	To:	Employer:	Telephone Number:
Starting Job Title:	Ending Job Title:	Employer's Address, City, State, Zip Code:
Supervisor and Title :		Summarize the nature of work and responsibilities :
Reason for leaving?		May we contact for reference? Yes No Later
Starting hourly rate/salary		Final hourly rate/salary

Job 2

From:	To:	Employer:	Telephone Number:
Starting Job Title:	Ending Job Title:	Employer's Address, City, State, Zip Code:
Supervisor and Title :		Summarize the nature of work and responsibilities :
Reason for leaving?		May we contact for reference? Yes No Later
Starting hourly rate/salary		Final hourly rate/salary

Job 3

From:	To:	Employer:	Telephone Number:
Starting Job Title:	Ending Job Title:	Employer's Address, City, State, Zip Code:
Supervisor and Title :		Summarize the nature of work and responsibilities :
Reason for leaving?		May we contact for reference? Yes No Later
Starting hourly rate/salary		Final hourly rate/salary

EDUCATIONAL BACKGROUND

	Name and Location	Number of years completed	Did you graduate?
High School:
College:
Other:

References

Name	Telephone	Number of years known

APPLICANT STATEMENT

I certify the information provided in this application is true and correct to the best of my knowledge. If employed, any miss-statement or omission of fact on this application may result in my dismissal.

I understand acceptance of an offer of employment does not create a contractual obligation or contract to continue my employment in the future.

I underrated if Hagopian decides to engage an investigative consumer credit reporting agency on my credit and personal history, I hereby authorize this engagement. If a report is obtained Hagopian must provide, at my request, the name of the reporting agency. I may obtain from the reporting agency the nature and substance of the information contained in the report.

I acknowledge, if at any time during my employment I am subjected to any type of harassment, including sexual harassment, I agree to immediately contact either my manager, or the H.R. Administrator in order to obtain assistance in the resolution of such matters.

I understand that I am employed at the mutual consent of myself and Hagopian. Consequently, I have the right to terminate my employment at any time, for any reason, with or without cause and Hagopian reserves the same right. This relationship is defined as “Employment At Will.”

I shall report all work-related injuries and/or illnesses that occur while on my work assignment to my manager within 24 hours of the incident. I understand all administration and/or payment of any claims will be provided by Hagopian’s Worker’s Compensation carrier. I also hold harmless Hagopian for any claim that may arise. I voluntarily acknowledge the exclusive remedy will be under Hagopian’s Worker’s Compensation policy.

I understand this agreement is for the benefit of Hagopian.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify I have read the agreement statement of this application.