IDENTIFICATION NAME (LAST, FIRST, MIDDLE) PRESENT MAILING ADDRESS (STREET AND NUMBER OR RFD) CITY STATE ZIP CODE SOCIAL SECURITY NUMBER DATE OF BIRTH DRIVER S LICENSE NUMBER STATE OF ISSUE HOME TELEPHONE NUMBER CELL TELEPHONE NUMBER ( ) ( ) OTHER NAMES IN WHICH EMPLOYMENT, MILITARY, OR EDUCATION RECORDS MAY BE FOUND POSITION APPLIED FOR SALARY DESIRED DAYS/HOURS AVAILABLE TO WORK EMPLOYMENT DESIRED WHEN AVAILABLE FOR WORK FULL TIME PART TIME EDUCATION HIGH SCHOOL HIGH SCHOOL OR GENERAL EDUCATION DEVELOPMENT TEST PASSED? YES NO SCHOOL LOCATION (CITY AND STATE) HIGHEST GRADE COMPLETED
POST HIGH SCHOOL TRAINING (COLLEGE, BUSINESS SCHOOL, MILITARY, ETC.) NAME OF SCHOOL LOCATION DEGREES RECEIVED ARE YOU AUTHORIZED TO WORK IN THE U.S.? NO YES HAVE YOU EVER BEEN CONVICTED OF A CRIME? NO YES If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. WORK EXPERIENCE Please list your work experience for the past five years beginning with your most recent job held. Attach additional sheets if necessary.
REFERENCES Please list two references other than relatives or previous employers. NAME NAME POSITION POSITION ADDRESS ADDRESS PHONE PHONE
ADDRESSES FOR PAST THREE YEARS Please list all of the cities and state in which you have lived in the past three years, the amount of time lived at each location, and any different names by which you were known at that time. 1. 2. 3. 4. 5. APPLICANT CERTIFICATION I hereby certify that this application contains no willful misrepresentation or falsifications and that the information given by me is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time disclose any such misrepresentation or falsification as to a material fact, my application will be rejected, I will be dismissed from the service, and, if applicable, my name will be removed from the Merit System register. SIGNATURE DATE AUTHORIZATION FOR RELEASE OF INFORMATION AND BACKGROUND CHECK I hereby authorize my previous employers or any educational institutions I have attended to release to CMMG, Inc. and information they may have regarding my character, academic record or employment history, whether on record or not. I also authorize any enforcement agency, or the Department of Revenue or other motor vehicle regulatory agency to allow any authorized representative of CMMG, Inc. to examine, copy, or receive any records pertaining to me regarding convictions or driving record. By authorizing the above, I agree to hold harmless and individual, partnership, corporation, educational institution or agency, its officers, agents and employees from any liability for any damage whatsoever for issuing such information. I further authorize CMMG, Inc. and its designated agents and representatives to conduct a comprehensive review of my background. I understand that the scope of the background check may include, but is not limited to the following areas: verification of social security number; credit reports; current and previous residences; employment history; education background; character references; drug testing; civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. SIGNATURE DATE
STATEMENT AND ACKNOWLEDGEMENT OF AT-WILL EMPLOYMENT As an employee of CMMG, your employment has been and continues to be at-will. This means that during the course of employment with the Company, employees are free to terminate their employment with the Company at any time, with or without a reason, and the Company has the right to terminate employees at any time, with or without a reason. Although the Company may choose to terminate an employee for cause, cause is not required. No one other than the President of the Company has the authority to alter this at-will employment arrangement, to enter into an agreement for employment for a specified period of time, or to make any agreement contrary to this at-will arrangement. Furthermore, any such agreement must be in writing and must be signed by the President of the Company. By signing in the space provided below, you hereby acknowledge that you have been given a copy of the Company s Statement and Acknowledgement of At-Will Employment, that you have read the Statement and that you understand its contents, and that you further understand that the Statement supersedes any and all previous agreements, policies, practices or guidelines, whether oral or written. APPLICANT Name: Date: Signature: Note to Applicant: If hired the original of this form will go into your personnel file. Click Here to Email Completed Form