Please return this application to Fairfield Cycle Center.
An Equal Opportunity Employer
_____________ ____________________________ ___________________________ ______________
Date Last Name First Name Middle
Present Address:
____________________________________________________ ______________________________________________________
Address City/State/Zip
Permanent Address (if different from present address):
____________________________________________________ ______________________________________________________
Address City/State/Zip
_________________________________ _________________________________ ____________________________________
Business Phone Home Phone Cell Phone
_________________________________ __________-___________-___________
Driver’s License Number/State Social Security Number
Position(s) Applying For: _________________________________________________________________
Date You Can Start: _______________________ Desired Starting Wage: $_______Per______
Have you ever applied to or worked for Fairfield Cycle Center before? € Yes € No
If Yes, when: _______________________________
Do you have friends or relatives working for Fairfield Cycle Center? € Yes € No
If Yes, state name(s) and relationship:
______________________________________________________ ___________________________
Name Relationship
______________________________________________________ ___________________________
Name Relationship
Why are you applying for work at Fairfield Cycle Center?
____________________________________________________________________________________________________________
If hired, would you have reliable transportation to and from work?………………………..€ Yes € No
Are you at least 18 years old? (If under 18, hire is subject to verification that
you are of minimum legal age)……………………………………………………………...€ Yes € No
If hired, can you present evidence of U.S. citizenship or proof of your legal
right to live and work in this country?……………………………………………..€ Yes € No
Are you able to perform the essential functions of the job for which you are
applying, either with or without reasonable accommodation?…………………….€ Yes € No
If No, describe the functions that cannot be performed.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants
/employees to perform essential functions. Hire may be subject to passing a medical exam and skill and agility tests)
Have you ever been convicted of a criminal offence (felony or serious misdemeanor)?…...€ Yes € No
(Convictions for marijuana-related offenses that are more than 2 years old need not be listed)
If Yes, state the nature of the crime(s), when and where convicted, and disposition of the case.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature, date, and surrounding circumstances and relevance of the offense to the position(s) applied for may, however, be considered.)
School Name & Address Yrs Completed Graduate Degree/Diploma
High _________________________________________________ ____________ € Y € N __________________
School Name Years
_________________________________________________ _____________________________________________
Address City/State/Zip
College/ _________________________________________________ ____________ € Y € N __________________
University Name Years
_________________________________________________ _____________________________________________
Address City/State/Zip
Vocational _________________________________________________ ____________ € Y € N __________________
Business Name Years
_________________________________________________ _____________________________________________
Address City/State/Zip
Other Training:
______________________________________________________________________________ __________________
Type of Training When
_________________________________________________ ____________ € Y € N __________________
Name of Provider Years
_________________________________________________ _____________________________________________
Address City/State/Address
Licenses/ ___________________________________________________________________________________________________
Certificates
___________________________________________________________________________________________________
List below all present and past employment, starting with your most recent employer (last 5 years is sufficient). Account for all periods of unemployment.
You must complete this section even if attaching a resume.
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Name of Employer Telephone Number
__________________________________________________ ______________________________________________________
Type of Business Your Supervisor’s Name
__________________________________________________ ______________________________________________________
Address City/State/Zip
Date of Employment: __________ ___________ Hourly or Weekly Pay: $_____/___ $_____/____
From To Starting Ending
____________________________________________________________________________________________________________
Your Position and Duties
____________________________________________________________________________________________________________
Reason for Leaving
May we contact this employer for a reference? Yes No
__________________________________________________ _____________________________
Name of Employer Telephone Number
__________________________________________________ ______________________________________________________
Type of Business Your Supervisor’s Name
__________________________________________________ ______________________________________________________
Address City/State/Zip
Date of Employment: __________ ___________ Hourly or Weekly Pay: $_____/___ $_____/____
From To Starting Ending
____________________________________________________________________________________________________________
Your Position and Duties
____________________________________________________________________________________________________________
Reason for Leaving
May we contact this employer for a reference? Yes No
Note: Attach additional page(s) if necessary.
References
List below 3 persons, not related to you, who have knowledge of your work performance
within the last 3 years.
_________________________________________ _________________________________ ___________________________
First Name Last Name Telephone Number
_______________________________________________________ _____________________________________________
Address City/State/Zip
_______________________________________________________ ____________________
Occupation No. of Years Acquainted
_________________________________________ _________________________________ ___________________________
First Name Last Name Telephone Number
_______________________________________________________ _____________________________________________
Address City/State/Zip
_______________________________________________________ ____________________
Occupation No. of Years Acquainted
_________________________________________ _________________________________ ___________________________
First Name Last Name Telephone Number
_______________________________________________________ _____________________________________________
Address City/State/Zip
_______________________________________________________ ____________________
Occupation No. of Years Acquainted
Please Read Carefully, Initial Each Paragraph and Sign Below
_____ I hereby certify I have not knowingly withheld any information that might adversely affect my
Initials chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
_____ I hereby authorize Fairfield Cycle Center (FCC) to thoroughly investigate my references, work
Initials records, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to FCC any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release FCC, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
_____ I understand that nothing contained in the application, or conveyed during my interview which
Initials may be granted or during my employment, if hired, is intended to create an employment contract between FCC and me. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or FCC and that no promises or representations contrary to the foregoing are binding on FCC unless made in writing and signed by me and FCC’s president.
_____ Should a search of public records (including records documenting arrest, indictment, conviction,
Initials civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by FCC, I am entitled to copies of any such public records obtained by FCC unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of such records even though I have checked the box below.
I waive receipt of a copy of any public record described in the paragraph above.
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Date Applicant Signature