Miracles Electrical Contractors, Inc.
2947-C Honolulu Ave., La Crescenta, CA 91214
Phone: (818) 248-1240 Fax: (818) 248-1449
State Contractors License # 782030
PRE-EMPLOYMENT APPLICATION
Our company is an equal opportunity employer and adheres to the principles and practices outlined in the Civil Rights Act of 1964, which prohibits discrimination in employment on the basis of race, sex, religion or national origin and Public Law 90-202 which prohibits discrimination based on age.
This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.
Applicants must respond to all questions. If not response is possible, (for example, if the applicant did not attend college) “None” should be entered on the appropriate line. Failure to complete all parts of this form will result in rejection of the application.
PERSONAL:
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DATE:
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Name:
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Home Phone:
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Last
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First
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Middle
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Current Address:
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Number
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Street
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City
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State
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Zip
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S.S. #:
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Are you over 18 yrs. old? Yes No
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Driver’s License:
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Currently Valid Currently Invalid / Do Not Have One
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Yr. Issued:________
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State:
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Number:
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Type/Class:
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Are you a citizen of the U.S., or do you have the legal right to be employed in the United States?
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Yes No
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Have you ever been convicted of any crime (excluding minor traffic violations) including DUI? (Note the term “conviction” includes pleas of no contest) Yes No If Yes, state the offense, location, date and disposition:
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Who should be contacted in case of emergency?
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Name
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Relationship
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Address
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Phone Number
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EMPLOYMENT DESIRED:
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What type of work are you seeking?
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Full Time
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Part Time
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Temporary or Summer/Seasonal
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Position applied for:
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Salary Desired:
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Date available to start:
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Ever applied to our company before?
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Yes No
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Ever worked for our company before?
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Yes No
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If your answer to either above question was Yes, state when and where you applied and/or worked.
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How did you learn of our company and/or position?
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Are you now, or do you expect to be engaged in any other business or employment?
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Yes No
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Are there any days or hours you would be unable or unwilling to work?
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Yes No
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If Yes, please specify:
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EDUCATION:
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Name & Location
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Dates
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Graduate?
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Courses Studied
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High School
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From:
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Diploma/ Certificate Yes No
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Yes
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To:
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No
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College
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From:
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Diploma/ Certificate Yes No
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Yes
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To:
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No
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Trade School
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From:
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Diploma/ Certificate Yes No
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Yes
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To:
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No
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If you did not graduate, why did you leave high school or college?
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Are you planning to pursue further studies?
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Yes No
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If Yes, when, where and what courses?
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List any scholastic honors, offices held and activities during high school and college:
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List and describe any other School or Specialized Training:
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HEALTH:
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Do you have any physical or mental defect or illness that may limit your ability to perform the particular job for which you are or applying, or which would prevent you from performing those functions in a manner which would not endanger your health and safety or the health and safety of others? Yes No
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If the Response is Yes, describe the nature and scope of reasonable accommodation which you believe would enable you to perform the essential functions of the job and/or perform these functions in a manner which would not endanger your health and safety or the health and safety of others. Attach an additional sheet if necessary.
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Date of last physical exam:
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Results:
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Have you ever been injured on the job?
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Yes No
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If Yes, please describe the injury:
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Nature of Injury
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Employer when Injured
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Year
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Cause of Injury
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1.
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2.
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3.
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4.
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Will you abide by the safety rules of this company?
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Yes No
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Are you willing to take a physical exam and a drug screen at the company’s expense?
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Yes No
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Have you ever received treatment for alcohol or drug use?
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Yes No
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Have you used any illegal drug, including marijuana, in the last 12 months?
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Yes No
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Days lost to illness in the last two years due to illness:
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Reason:
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WORK HISTORY:
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If you worked in any of your previous positions under another name, please give that name.
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Are you presently employed?
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Yes No
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If Yes, may we contact your present employer?
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Yes No
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Have you ever filed an employment related lawsuit (excluding a worker’s compensation or unemployment benefit claim against a former employer? Yes No If Yes, give details:
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Please list the names of employers in consecutive order with present or most recent listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.
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Name and Address of Employer
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Name & Title of Last Supervisor
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Dates Employed
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Pay
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From
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Starting:
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Month:
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$
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Year:
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per
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To
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Ending
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Month:
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$
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Year:
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per
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Telephone
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Nature of Business:
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Last Title:
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Reason Leaving:
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Duties:
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Name and Address of Employer
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Name & Title of Last Supervisor
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Dates Employed
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Pay
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From
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Starting:
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Month:
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$
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Year:
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per
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To
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Ending
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Month:
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$
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Year:
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per
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Telephone
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Nature of Business:
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Last Title:
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Reason Leaving:
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Duties:
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Name and Address of Employer
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Name & Title of Last Supervisor
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Dates Employed
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Pay
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From
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Starting:
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Month:
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$
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Year:
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per
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To
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Ending
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Month:
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$
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Year:
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per
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Telephone
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Nature of Business:
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Last Title:
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Reason Leaving:
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Duties:
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Name and Address of Employer
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Name & Title of Last Supervisor
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Dates Employed
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Pay
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From
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Starting:
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Month:
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$
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Year:
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per
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To
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Ending
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Month:
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$
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Year:
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per
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Telephone
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Nature of Business:
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Last Title:
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Reason Leaving:
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Duties:
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SPECIAL SKILLS:
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Do you type?
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Yes No WPM:
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Do you take Shorthand?
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Yes No WPM:
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What languages do you speak fluently?
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Please list any computer programs in which you are proficient, as well as the last date you used the program.
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Program
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Version
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Windows or MAC?
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Type, e.g. wp, d-base, etc.
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Date Last Used
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REFERENCES:
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Give three references, not relatives or former employers:
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Name
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Address
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Phone
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Occupation
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1.
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2.
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3.
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TERMS AND CONDITIONS OF EMPLOYMENT
1. Any offer of employment by Miracles Electrical Contractors, Inc. is conditioned upon the applicant providing acceptable proof of identity and authorization to work in accordance with the immigration laws of the United States. Any offer of employment is further conditioned upon the results of a medical examination, if such an examination is required of applicants for the position for which the application is made.
2. Offers of employment with Miracles Electrical Contractors, Inc. are also conditioned upon the execution of an employment dispute arbitration agreement, which must be signed and returned to the company’s Human Resources department prior to the applicant beginning work with the company.
CERTIFICATION
I certify that the responses by me to inquire in this pre-employment application are true and correct to the best of my knowledge and belief. I understand and agree that any false or misleading statements on this application shall be grounds for the rejection of my application, or, if I am employed, the immediate termination of my employment upon discovery, without further notice or warning. I understand and agree that my employment with the company shall have no specified term, and may be terminated by me or The Company at any time, with or without cause, upon notice to the other. I also understand that this at-will status can be altered only by a written agreement signed by the President of The Company and by me.
ACKNOWLEDGEMENT
I acknowledge that I have read and understand the terms and conditions of employment set out above. I understand that these terms and conditions of employment supersede all prior representations made to me by The Company before or during the execution of this application form, and I further acknowledge that they contain all of the agreements between The Company and myself with respect to the subjects covered. In consideration of employment with Miracles Electrical Contractors, Inc., I agree to be bound by each of these terms and conditions during by employment with The Company.
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Applicant’s Signature
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Date
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Note: In the event that the applicant is not hired, this application will expire thirty (30) days from the date on the application.