Malcom Baldridge National Quality Award

Employment Application

Position of Interest:
PERSONAL DATA
Last Name
 First
 Middle
 Date
Street Address
 Home Phone #
City
 State
 Zip
 Other Phone #s
Driver's License Number
Are you legally authorized to work in the U.S.A.? Yes No
Are you under 18 years of age? Yes No If yes, state age
Note: If under 18 years of age, employment subject to minimum legal age requirements.
Have you previously applied for employment with us? Yes No
If yes: Month and Year Hired: Yes No
Do you have relatives that are currently employed here at Branch-Smith? Yes No
If yes, what is his or her name?
How did you find out about us?
Have you ever been convicted of a felony? Yes No
Disclosure of criminal record does not automatically disqualify you from employment consideration. Your case will be judged on its own merits.
Describe in detail:
Have you served in, or currently a member of, the U.S. Reserve, National Guard or any branch of the U.S. Armed Forces: Yes No
Discharge Status:
EDUCATION
TypeName/Location of SchoolCourse of StudyDid you Graduate?Degree or Diploma
High School Yes
No
Trade/ Technical Yes
No
College Yes
No
Graduate Yes
No
Additional Training
EMPLOYMENT
May we contact your current and/or previous employers? Yes No
Employment History
Please give accurate, complete full-time/part-time employment record. Start with your present or most recent employer.
Present or Last Employer
Company Name
 Telephone
Address
 Employment Dates
From To
Name of Supervisor
 Weekly Pay
Start Last
State Job Title and Describe Work
 Reason For Leaving
Previous Employer
Company Name
 Telephone
Address
 Employment Dates
From To
Name of Supervisor
 Weekly Pay
Start Last
State Job Title and Describe Work
 Reason For Leaving
Previous Employer
Company Name
 Telephone
Address
 Employment Dates
From To
Name of Supervisor
 Weekly Pay
Start Last
State Job Title and Describe Work
 Reason For Leaving
Previous Employer
Company Name
 Telephone
Address
 Employment Dates
From To
Name of Supervisor
 Weekly Pay
Start Last
State Job Title and Describe Work
 Reason For Leaving
Please provide an explanation for any gaps in employment:
Please list any additional skills and abilities you have that would be of use in the position you are applying for:
Have you ever been involuntarily terminated from employment? Yes No
If yes, please explain:

JOB APPLICANT AGREEMENT

PLEASE READ CAREFULLY

I hereby affirm that my answers to all statements and questions are true and correct to the best of my knowledge. I have not knowingly withheld any fact or circumstance that would, if disclosed, affect my application unfavorably. I understand Branch-Smith Printing and Branch-Smith Publishing require certain information about me to evaluate my qualifications for employment and conduct in business if I become an employee. I understand that false, incomplete, or misleading statements on this application or any other company record may be considered sufficient cause for dismissal, when discovered.

I understand that this company will attempt to verify statements made on my application and during my employment interviews. I authorize this company to investigate my personal history, employment history, and educational background through the investigative or credit agency of its choice. I understand this company may obtain or prepare a consumer report or investigative consumer report in connection with my application for employment. I authorize any reference, former employer, credit bureau, school, law enforcement agency, government agency or any other person to furnish to this company and/or its agents or representatives any information they have concerning me. I further authorize the release of any records or data pertaining to me including motor vehicle records or any other public records. I release any such persons or entities from all liability for disclosing such information to this company. I understand that I have the right to make a written request within a reasonable time period for a complete and accurate disclosure of the nature and scope of the investigation requested.

I understand that I have the right to terminate my employment at any time with or without notice, with or without cause, and that this company has a similar right.

I understand that any offer of employment is conditional on the successful completion of a test for drug/alcohol abuse and may be conditional upon the successful completion of a physical exam for the purposes of determining my ability to perform the essential functions of the job. I will upon request, sign all necessary consent forms.

The Immigration Reform and Control Act of 1986 requires that after employment, employers verify the legal work authorization and identity of all new employees. An offer of employment will depend upon this company's ability to verify this necessary information.

I have read the above applicant agreement and understand its terms.