USA Brake and Auto Repair - New Employee Information

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Please fill out the following form to submit your application for employment. Your information is secure and safe as this page, and how it is sent to us, is fully encrypted.

Employee Data

Name: Last: First: M.I. Social Security Number:

Current Address: City: State: Zip:

Email: Phone: How long have you resided at current address?

Prior Address: City: State: Zip:

Phone: How long did you reside at prior address?

Are you over 18 years of age? Sex:

Have you worked for this company in the past? If so, when?

Names of friends or relatives who presently work for this company:

Emergency Contact Information

Name: Home Phone:

Address: Work Phone:

City: State: Zip:

How is this person related to you?

Position Desired

Position: Date you can start work:

Are you currently employed? If so, may we contact your current employer?

Employment History and Educational Background

List your past three (3) employers, beginning with the most recent.

	Company	Address	Phone	Supervisor
1.
2.
3.

List the past three (3) schools you attended, beginning with the most recent.

	Name and Address	Years Completed	Did you graduate?	Major/Degree
1.
2.
3.

General

List any foreign languages you speak and check your level of fluency:

Minimal Fluent Read Write

List and special skills/abilities you have that can be applied to this position:

Resume - If you would like to submit your resume, please use the area below to do so:

Security

Have you ever been bonded? If so, explain:

Have you been convicted of a felony within the past 5 years?

If so, explain (this will not necessarily exclude you from consideration):

Authorization

REQUIRED - CHECK THIS BOX IF YOU AGREE - 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 will be grounds for dismissal.

- IF FORM DOES NOT SUBMIT PLEASE CHECK FOR RED HIGHLIGHTED AREAS ABOVE THAT ARE REQUIRED