Applicant Information

Full Name:

Date:

Last

First

M.I.

Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

Previous Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

Phone:

( )

E-mail Address:

Date Available:

Desired Salary:

$

Position Applied for:

Are you a citizen of the United States?

YES

NO

If no, are you authorized to work in the U.S.?

YES

NO

Have you ever worked for this company?

YES

NO

If yes, when?

Have you ever been convicted of a felony?

YES

NO

If yes, explain:

Education

High School:

Address:

From:

To:

Did you graduate?

YES

NO

Degree:

College:

Address:

From:

To:

Did you graduate?

YES

NO

Degree:

Other:

Address:

From:

To:

Did you graduate?

YES

NO

Degree:

References

Please list three professional references.

Full Name:

Relationship:

Company:

Phone:

( )

Address:

Full Name:

Relationship:

Company:

Phone:

( )

Address:

Full Name:

Relationship:

Company:

Phone:

( )

Address:

Previous Employment

Company:

Phone:

( )

Address:

Supervisor:

Job Title:

Starting Salary:

$

Ending Salary:

$

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

YES

NO

Company:

Phone:

( )

Address:

Supervisor:

Job Title:

Starting Salary:

$

Ending Salary:

$

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

YES

NO

Company:

Phone:

( )

Address:

Supervisor:

Job Title:

Starting Salary:

$

Ending Salary:

$

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

YES

NO

Military Service

Branch:

From:

To:

Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. (A) Should I need any assistance in the application process or a reasonable accommodation to perform the duties of the job or position for which I am applying because I have a physical or mental disability, I will advise the person processing my application. I further acknowledge that as part of the interview process, I may be requested to demonstrate my ability to actually perform certain tasks that are a part of the key responsibilities of the job. I further agree and do expressly waive and release any and all claims I might otherwise have by reason of any accident, injury or condition which may occur during any such demonstration of my ability and capacity to perform such task or tasks. By execution of this agreement I hereby release Bush Brothers and Company, its servants and employees from liability for any such claim or claims and agree to indemnify, save and hold harmless, Bush Brothers and its agents, officers, servants, and employees from any such liability. (B) When I accept an offer of employment, I am agreeing to submit to a physical examination by a doctor designated by Bush Brothers and Company, including X-rays, blood tests, and urine test if the physician deems those appropriate. It is also specifically understood that I will submit to a drug test. I understand that my commencement of employment is contingent upon the results of the physical examination indicating that I can perform the key responsibilities of the job for which I have applied and that the drug test reflects I am not using illegal drugs. (C) I have been advised and accept as conditions of my employment, the fact that the Company has a drug testing policy which provides that I may be tested (1) at any time it appears I am “under the influence of alcohol and/or drugs,” (2) in the event I have involved in any accident on the job which results in substantial property damage or injury to my self or another person requiring medical treatment or (3) because I have been selected to be tested under the Company’s random testing procedures. (D) When I accept an offer of employment, I am agreeing to furnish Bush Brothers and Company with complete information on my current health, health history and workers’ compensation claim history with the understanding that this information will be retained in confidential files and not released to anyone other than authorized Bush employees or the Company’s attorneys without my specific written authorization or where the information is required by federal or state laws. (E) In consideration of the Company furnishing me with a locker or furniture with storage space, I agree not to store any items in the property or on the Company’s premises that would constitute a violation of any Company policy or state, local or federal law. By my acceptance of employment and my commencement to use such lockers, furniture or other storage space, I am consenting to the search of any Company property which I have or have had the use of.