Employment

Application for Employment
(Pre-employment questionnaire equal opportunity employer)

Personal information
Name (Last, First, MI:
Social Security No.:
Current Address:
     
City:
 		State:
 		Zip Code:
Phone Number:
E-mail Address:
Referred By:
Employment Desired
Position:
Date You Can Start:
 		Salary Desired:
Are you employed?:
 		Ever Applied before?:
If so may we inquire of your current employer?:
Education
High School:
 		Years Attended:
 		Did you graduate?:
College:
 		Years Attended:
 		Did you graduate?:
Subjects Studied:
Trade, business, or correspondence:
 		Years Attended:
 		Did you graduate?:
Subjects Studied:
General
 (Subjects of special study/research work or special training/skills)
U.S. Military or Naval Service:
Rank:
Former Employers
 (list below last four employers, starting with last one first)
1





Name & Address of Employer:
From:
 		To:
Salary:
 		Reason for leaving:
Contact Person:
 Phone Number:
2

 

 

Name & Address of Employer:
From:
 		To:
Salary:
 		Reason for leaving:
Contact Person:
 Phone Number:
3

 

 

Name & Address of Employer:
From:
 		To:
Salary:
 		Reason for leaving:
Contact Person:
 Phone Number:
4

 

 

Name & Address of Employer:
From:
 		To:
Salary:
 		Reason for leaving:
Contact Person:
 Phone Number:
Resume
 (Please cut and paste resume here)
How Did  you here About Us?
TV Radio Friend WWW Other
Authorization
"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 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 company from all liability for any 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 representative."

I agree to the above authorization:


We Offer Statewide Mobile Service
And Direct Insurance Billing

Plymouth Glass & Mirror, Inc.
142 Main Street - Thomaston, CT 06787
1-800-227-0262 - Fax (860) 283-6006