Employment Application

We are an equal opportunity employer. Race, color, religion, sex, and national origin or any other basis protected by statute are not factors in employment, promotion and compensation. The Bug Man, Inc. drug tests and checks your driving record with the Arkansas State Police Department. Signing below authorizes these procedures.

All positions are located in the state of Arkansas

Position(s) applying for :

Date :

How where you referred to our company?	Agency Ad Employee Job Fair College Relations
	Other

Do you wish to refer a friend or co-worker?

Yes No

Personal Information

First Name :

Middle Name :

Last Name :

Address Line 1 :

Address Line 2 :

City :

State :

Zip Code :

Home Phone :

Business Phone :

Email Address :

Social Security Number :

Upon employment, can you submit documents verifying your legal right to work in the United States? Yes No

Are you over age 18? Yes No Date of Birth : Marital Status :

Number of Children :

Name			Birth Date
Name			Birth Date
Name			Birth Date
Name			Birth Date
Name			Birth Date
Name			Birth Date

Employment Desired

Have you ever applied for employment and/or work for our Company in the past? Yes No

Are you currently on layoff or leave from another company? Yes No

Are you available for full-time work? Yes No

Date that you can start : Salary Requirements : $

List applicable skills :

Education

School	Name of School	Location of School	# Years	Did You Graduate?	Degree or Diploma
College
High School					Yes No
Elementary
Other

Training / Certifications Completed or Currently Pursuing

COURSE	LOCATION	DESIGNATION/CERTIFICATION	DATE COMPLETED/EXPECTED COMPLETION

Employment History

List employment for the past 10 years, starting with present job. Include military experience.
Please explain any gaps in employment history on the Comment lines on last page.

Company Name :

Street Address :

City :

State :

Zip :

Telephone Number :

Job Title :

Supervisor :

Start Date :

End Date :

Reason For Leaving :

Specific Duties :

May We Contact?

Yes No

Salary :

Other Compensation :

Click here to add more employment history.

Company Name :

Street Address :

City :

State :

Zip :

Telephone Number :

Job Title :

Supervisor :

Start Date :

End Date :

Reason For Leaving :

Specific Duties :

May We Contact?

Yes No

Salary :

Other Compensation :

Click here to add more employment history.

REFERENCES

Name	Company / Relationship to You	Business Phone	# Years Known

EMERGENCY

(In case of emergency, please notify:)

Name :
Address :
Phone :

EMPLOYMENT LIMITATIONS

Can you perform essential functions of the job, as you understand them, without a problem?
Yes No

THE FOLLOWING STATEMENTS ARE PART OF THE APPLICATION. PLEASE READ THEM CAREFULLY AND INITIAL BELOW.

I certify that all statements made by me on this application are true and complete to the best of my knowledge and I have nothing which, if disclosed, would affect this application unfavorably. I understand that if the Company determines that any of the information is false, the Company may reject my application. I further understand that should the Company offer me a position and it subsequently discovers that any information is false, that my employment will be subject to immediate termination.

I authorize my previous employers, schools or persons named as references to give any information regarding employment or educational record. I further authorize the Company to contact any other persons suggested by such employers, schools, or references. I agree that this company, my previous employers or any other person I have authorized the Company to contact shall not be held liable in any respect if a job offer is not extended, is withdrawn, or my employment is terminated because of false statements, omissions or answers made by me on this application.

If I am employed with this Company, I will comply with all rules and regulations as set forth in any communication distributed to employees.

I understand should I be employed by the Company, I will be required, in accordance with the Immigration Reform and Control Act of 1986, to provide, upon my first day of employment, documents providing proof of my identity and employment eligibility status. I acknowledge that this verification is a condition of employment. I hereby acknowledge that I have read and understand the above statements.

Initials :
Date :

Comments :