Application for Employment

APPLICATION FOR EMPLOYMENT

FRANKLIN WELL SERVICES, LLC

(PRE-EMPLOYMENT QUESTIONNAIRE) (AN EQUAL OPPORTUNITY EMPLOYER)

PERSONAL INFORMATION

NAME

LAST

FIRST

MIDDLE

PRESENT ADDRESS

STREET

CITY

STATE

ZIP

PERMANENT ADDRESS

STREET

CITY

STATE

ZIP

PHONE NO.

ARE YOU 18 YEARS OR OLDER?

Yes No

ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS?

Yes No

EMPLOYMENT DESIRED

POSITION

DATE YOU CAN START

SALARY DESIRED

ARE YOU EMPLOYED NOW?

IF SO MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?

EVER APPLIED TO THIS COMPANY BEFORE?

WHEN?

HAVE YOU EVEN BEEN CONVICTED OF A FELONY, OR A MISDEMEANOR INVOLVING ANY VIOLENT ACT, USE OR POSSESSION OF A WEAPON, OR ACT OF DISHONESTY FOR WHICH THE RECORD HAS NOT BEEN SEALED OR EXPUNGED, OR DO YOU HAVE SUCH A CASE PENDING?

Yes No

IF YES, PLEASE EXPLAIN IN DETAIL (CONVICTIONS ARE EVALUATED ON A CASE-BY-CASE BASIS FOR EACH POSITION AND ARE NOT AUTOMATICALLY DISQUALIFYING.)

EDUCATION

GRAMMAR SCHOOL

NAME AND LOCATION OF SCHOOL

*NO. OF YEARS ATTENDED

*DID YOU GRADUATE?

SUBJECTS STUDIED

HIGH SCHOOL

NAME AND LOCATION OF SCHOOL

*NO. OF YEARS ATTENDED

*DID YOU GRADUATE?

SUBJECTS STUDIED

COLLEGE

NAME AND LOCATION OF SCHOOL

*NO. OF YEARS ATTENDED

*DID YOU GRADUATE?

SUBJECTS STUDIED

TRADE BUSINESS OR CORRESPONDENCE SCHOOL

NAME AND LOCATION OF SCHOOL

*NO. OF YEARS ATTENDED

*DID YOU GRADUATE?

SUBJECTS STUDIED

*This form has been revised to comply with the provisions of the Americans with Disabilities Act and the final regulations and interpretive guidance promulgated by the EEOC on July 26, 1991.

GENERAL

SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK

SPECIAL SKILLS

ACTIVITIES: CIVIC, ATHLETIC, ETC. EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED, SEX, AGE, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS.

U S MILITARY OR NAVAL SERVICE

RANK

PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES

FORMER EMPLOYERS

LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST].

EMPLOYER #1

START DATE

END DATE

NAME AND ADDRESS OF EMPLOYER

SALARY

POSITION

REASON FOR LEAVING

EMPLOYER #2

START DATE

END DATE

NAME AND ADDRESS OF EMPLOYER

SALARY

POSITION

REASON FOR LEAVING

EMPLOYER #3

START DATE

END DATE

NAME AND ADDRESS OF EMPLOYER

SALARY

POSITION

REASON FOR LEAVING

WHICH OF THESE JOBS DID YOU LIKE THE BEST?

WHAT DID YOU LIKE MOST ABOUT THE JOB?

REFERENCES

GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.

REFERENCE #1

NAME

ADDRESS

BUSINESS

YEARS ACQUAINTED

REFERENCE #2

NAME

ADDRESS

BUSINESS

YEARS ACQUAINTED

REFERENCE #3

NAME

ADDRESS

BUSINESS

YEARS ACQUAINTED

Signature of Applicant

IN CASE OF EMERGENCY NOTIFY

NAME

ADDRESS

PHONENO.

"I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED, MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME.
IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY’S RULES AND REGULATION, AND I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY’S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AND ANY TIME BY THE COMPANY. I UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN ITS PRESIDENT, AND THEN ONLY WHEN IN WRITING AND SIGNED BY THE PRESIDENT, HAS ANY AUTHORITY OR ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING."

SIGNATURE

DATE