Position Applied For

PERSONAL DATA

Name*

First Middle Last

Email*

Address

Street Address Address Line 2 City State ZIP Code

Phone

If you are under 18 years of age, please specify your age here

This information will be used only for child labor law purposes

Are there any days, shifts or hours you will not work?

Yes
No

If Yes, please explain

When will you be able to start work?

Have you taken any illegal drugs in the last 30 days?

Yes
No

Are you legally authorized to work in the United States?

Yes
No

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification "FORM I-9" be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

DRIVING RECORD

(Answer only if driving is a requirement of the job for which you are applying)

State

License Number

RESIDENCES

(Part 391.21 (b)(3))(Please provide your addresses of residence for the past seven years beginning with the most recent address.)

Address

Street Address Address Line 2 City State ZIP Code

From

To

Education

(May or may not be considered depending on job applied for.) Describe any educational degrees, skill, training or experience you believe are relevant to the job applied for:

High School

Graduated

Yes
No

If not Degree, Credits earned

Type of Degree Received or Expected

Major

Minor

Overall GPA

College or University

Graduated

Yes
No

If not Degree, Credits earned

Type of Degree Received or Expected

Major

Minor

Overall GPA

College or University

If not Degree, Credits earned

Type of Degree Received or Expected

Major

Minor

Overall GPA

Graduated

Yes
No

EMPLOYMENT HISTORY

(Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis)

Company Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Date Employed From

To

Name of Supervisor

May we contact

Yes
No

Rate of Pay Start

Last

State job titles and description job duties

Reason for Leaving

REFERENCES

(Please list three persons not related to you who know your qualifications.)

Name

Relationship

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name

Relationship

Phone

Address

Street Address Address Line 2 City State ZIP Code

Have you ever been discharged or forced to resign?

Yes
No

If yes, explain

Have you signed any non-compete or non-solicit agreement with any other employer that might restrict you from working for this company?

Yes
No

If yes, please explain

(You may be required to furnish a copy of the agreement)

LIE DETECTOR TESTS

Massachusetts Applicants Note: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Maryland Applicants Only: An employer may not require or demand, as a condition of prospective employment or continued employment, an individual submit to or take a lie detector or similar tests. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100. I have read and acknowledge this notice:

CRIMINAL RECORD INFORMATION

Read the Terms and Conditions

1. Have you been convicted of a felony within the last seven years?

Yes
No

Date of Conviction

2. Have you been convicted within the last seven years of misappropriation of funds, embezzlement, or similar for other dishonest conduct; or an offense involving the use of a weapon; for burglary, robbery, breaking and entering or theft; or physical assault or other violent crime?

Yes
No

3. Have you been convicted of or completed a period of incarceration within the past five years for any misdemeanor?

Yes
No

If the answer to the above question is "yes," please state whether you were convicted more than five years ago for any offense?

4. A criminal conviction will not necessarily be a bar to employment. To help us evaluate your application, please describe your criminal conviction(s) including penalty (ies) imposed, listing the nature of your offense(s), and your rehabilitation

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Work for Dr. Shel Wellness & Aesthetic Center in Sugar Land

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EMPLOYMENT HISTORY

REFERENCES

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CRIMINAL RECORD INFORMATION

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