CLEARR VISSION SUPPORT SERVICES, INC. - Employment Application

Employment Application

Programs, services and employment are equally available to everyone. Please inform the Human Resources Department if you require reasonable accommodation for the application or interview.

Application Data
How were you referred to us?
Position Applied For:
First name*
Last name*
Email*
Phone number:*
Mobile/Pager/Other Phone Number:
Address
City
State
Zip code
Date Available To Start:
Social Security Number/ T- Number
Salary Requirement:
If you are under the age of 18 can you provide a work permit?
If no please explain:
Do you have any criminal charges (including traffic violations)?
If yes please list:
Have you ever worked for this company?
If yes when?
Are you legally allowed to work in the United States?
Type of employment desired:
Driver's license number if applicable to position:
State:
Education History
Name & Location of High School:
Did you graduate High School?
Name and Location of College:
Years attended:
Degrees completed:
Other subjects studied:
Trade or Business or Correspondence School?
Years attended:
Did you graduate?
Summarize Your Special Skills or Qualifications
List below:
Previous Employment (begin with most recent position):
Dates of Employment ( From - To)
Position(s) held:
Company Name:
Company address:
City:
State:
Zip Code:
Phone:
Supervisor:
Title:
Responsiblities
Starting Salary & Title
Ending Salary & Title
Reason for leaving:
May we contact this employer for a reference?
Previous Employment
Dates of Employment ( From - To)
Position(s) held:
Company name:
Company Addres:
City
State
Zip
Phone
Supervisor
Title
Responsiblities
Starting Salary & Title
Ending Salay & Title
Reason for leaving:
May we contact this employer for a reference?
Previous Employment
Dates of Employment ( From - To)
Position(s) held:
Company name:
Company address:
City
State
Zip
Phone
Supervisor
Title
Responsiblities
Starting Salary & Title
Ending Salary & Title
Reason for leaving:
May we contact this employer for a reference?

I certify that the facts contained in my 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 many 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 of 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 company representative. This wavier 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. Type your initials to provide online confirmation that you have read and agree to the above statement.*
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