Employment application for Lubri-Care Distributors of CT Inc.

* = Required

Personal Information

Employment Desired

Position:
Date you can start:
Salary Desired:
Are you employed?	Yes No
If so, may we inquire of your present employer?	Yes No
Ever applied to this company before?	Yes No
Where?
When?

Education History

Grammar School:
Years attended:
Did you graduate?	Yes No
Subjects Studied:

High School:
Years attended:
Did you graduate?	Yes No
Subjects Studied:

College:
Years attended:
Did you graduate?	Yes No
Subjects Studied:

Trade, Business or Correspondence School:
Years attended:
Did you graduate?	Yes No
Subjects Studied:

General Information

Subjects of special study/research work or special training/skills:
U.S. Military or Naval Service:
Rank:

Former Employers

List below last four employers, starting with last one first
From:
To:
Employer Name and Address:
Salary:
Reason for leaving:

From:
To:
Employer Name and Address:
Salary:
Reason for leaving:

From:
To:
Employer Name and Address:
Salary:
Reason for leaving:

From:
To:
Employer Name and Address:
Salary:
Reason for leaving:

References

Give below the names of three persons not related to you, whom you have known at least one year.
Name:
Address:
Business:
Years known:

Name:
Address:
Business:
Years known:

Name:
Address:
Business:
Years known:

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Authorization

"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 shall be grounds for dismissal. I authorize investigation of all statements contained herein and the reference and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may 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 for 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 waiver 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."
Date:
* Signature:	(Type name in box; this represents your signature in agreeing to the above)

Note: All information remains confidential and will not be shared with anyone.