Job Application

Today's Date: *

First Name: *

Last Name: *

Phone: *

Email: *

Street Address: *

Address Line 2:

City: *

State / Province / Region: *

ZIP / Postal Code: *

Position: *

Date You Can Start: *

Salary Desired: *

Are You Employed?

If so, may we inquire of your present employer?

Employer's Phone Number:

Ever Applied to this Company Before?

When?:

(Check all that apply)

(Check all that apply)

(List below last four employers, starting with the last one first)

Date (Month & Year):

Name & Address of Employer:

Salary:

Position:

Reason For Leaving:

Date (Month & Year):

Name & Address of Employer:

Salary:

Position:

Reason For Leaving:

Date (Month & Year):

Name & Address of Employer:

Salary:

Position:

Reason For Leaving:

Date (Month & Year):

Name & Address of Employer:

Salary:

Position:

Reason For Leaving:

(Give below the names of three persons not related to you, whom you have known at least one year)

Name

Phone Number:

Business:

Years Known:

Name

Phone Number:

Business:

Years Known:

Name

Phone Number:

Business:

Years Known:

"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 statement contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release The Roof Authority, Inc. from all liability for any damage that may result from utilization of such information. I also understand that no representative of The Roof Authority, Inc. 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 authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

I Agree*