CHILLER SPECIALTIES APPLICATION FOR EMPLOYMENT Full Name * Email * Home Phone * Mobile Phone * Work Phone Home Address * City * State * - - Choose One - - AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE PR QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT Zip * Position Applying For Date You Can Start Salary / Hourly Wage Desired Are You Presently Employed * Yes No If So, May We Inquire of Your Present Employer Yes No Have You Ever Applied at This Company? * Yes No CURRENT / FORMER EMPLOYERS - PLEASE PROVIDE REQUESTED INFORMATION ON YOUR MOST RECENT 3 EMPLOYERS, STARTING WITH THE LATEST ONE FIRST. Employer / Company (Current/Most Recent) - 1 * Position * From * To * Employer / Company 2 Position From To Employer / Company 3 Position From To EDUCATION HISTORY Elementary School Graduation Year High School Graduation Year College Years Completed Major / Degree Graduation Year Trade, Business, or Correspondence School Years Completed REFERENCES - PLEASE LIST 3 PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR. Reference 1 Name * Reference 1 Phone * Reference 1 Relationship * Reference 1 - Years Known * Reference 2 Name * Reference 2 Phone * Reference 2 Relationship * Reference 2 - Years Known * Reference 3 Name * Reference 3 Phone * Reference 3 Relationship * Reference 3 - Years Known * AUTHORIZATION By submitting this application, 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. I authorize investigation of all statements contained herein and the references and employers listed and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and releases this company from liability for an damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the American with Disabilities Act (ADA) and other relevant federal and state laws. Authorized by (Your Name) * Today's Date * Security Code *