Employment

Position you are applying for:*

Today's Date *

Date of Birth*

Social Security Number*

Name*

First

Last

Address

Street Address City State Postal / Zip Code

Email*

Home Phone*

Cell Phone

Emergency Contact Name

Relationship

Emergency Contact Phone Number

Do you have a valid Driver's license?*

Yes

No

Drivers License State Issued*

Drivers License Number*

Do you have a CDL license?

Yes

No

Passenger Endorsement?

Yes

No

Are you legally eligible for employment in the US? *

Yes

No

Have you ever been employed by Russell Specialty Services, LLC? *

Yes

No

If yes, when?

Have you ever owned/operated your own business?*

Yes

No

If yes, Where?

Have you ever worked in the service industry?*

Yes

No

If yes, Where?

How did you hear about this position?*

Type of work desired*

Full Time

Part Time

Why do you feel you are qualified for this job? *

Do you know anyone who works for Russell Specialty Services, LLC?*

Yes

No

If yes, who?

Transportation is not provided, how will you get to work?*

What hours are you available to work? *

Are there any days or times you are absolutely NOT available?*

Have you ever been convicted of a crime?*

Yes

No

If yes, please describe below

EDUCATION

SPECIAL SKILLS AND QUALIFICATIONS: List job-related licenses, skills, training, honors, awards, special accomplishments & acquired skills:

MILITARY SERVICE RECORD

Were you in the US Armed Forces

Yes

No

Did you receive any training in the U.S. Armed Forces that is relevant to the position applied for?

Yes

No

If yes, please explain

EMPLOYMENT HISTORY

Employer Name (1)

Address

Street Address Street Address Line 2 City State Postal / Zip Code Country

Supervisor's Name

Phone

Position Title

Dates Employed From _________ To __________

Describe the work you did

Wages Earned

Reason for leaving

Employer Name (2)

Address

Street Address Street Address Line 2 City State Postal / Zip Code Country

Supervisor's Name

Phone

Position Title

Dates Employed From _________ To __________

Describe the work you did

Wages Earned

Reason for leaving

Employer Name (3)

Address

Street Address Street Address Line 2 City State Postal / Zip Code Country

Supervisor's Name

Phone

Position Title

Dates Employed From _________ To __________

Describe the work you did

Wages Earned

Reason for leaving

Employer Name (4)

Address

Street Address Street Address Line 2 City State Postal / Zip Code Country

Supervisor's Name

Phone

Position Title

Dates Employed From _________ To __________

Describe the work you did

Wages Earned

Reason for leaving

Employer Name (5)

Address

Street Address Street Address Line 2 City State Postal / Zip Code Country

Supervisor's Name

Phone

Position Title

Dates Employed From _________ To __________

Describe the work you did

Wages Earned

Reason for leaving

I hereby give permission to contact the employers listed above concerning my prior work experience*

Yes

No

IF you do not want us to contact your present employer, please indicate here

Please Read:

The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on this application may result in my dismissal. I also understand that this application is not intended to be a contract of employment. Furthermore, this application does not obligate the employer in any
way if the employer decides to employ me. You are hereby authorized to make any investigation of my personal history and financial and credit record through any investigative agencies, credit agencies, or bureaus of your choice. I understand that I have the right to make a written request within a reasonable period of time to receive
additional, detailed information about the nature and scope of any investigative report that is made.

Electronic Signature

Date

PERSONAL REFERENCES

Name, Address, Phone Number

Name, Address, Phone Number (2)

Name, Address, Phone Number (3)

WORK REFERENCES

Name, Occupation, Address, Phone Number

Name, Occupation, Address, Phone Number (2)

Name, Occupation, Address, Phone Number (3)

Employment

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