Application for Employment at Fisher59 Date NameFirstLastMiddle Address Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country Home Phone Cell Phone Business Phone Have you ever applied for employment with us?YesNo If Yes: Please specify Month and Year LocationSelect OneFisher59 - DentonFisher59 - Wichita FallsFisher59 - Lawton Position Desired Are you interested in:Full TimePart TimeDay ShiftTemporaryEvening Shift If not, what hours can you work? Are you available for full-time work?YesNo Will you work overtime if asked?Yes No Pay Expected USD Are you eligible for employment in the United States? When will you be available to begin work? Other special training or skills How did you learn of our organization?COLLEGE Name and Location of School (College) Course of Study (College) No. of Years Completed (College) Degree or Diploma (College) Did you Graduate? (College)YesNoHIGH SCHOOL Name and Location of School (High School) Course of Study (High School) Degree or Diploma (High School) No. of Years Completed (High School) Did you Graduate? (High School)YesNoELEMENTARY Name and Location of School (Elementary) Course of Study (Elementary) Degree or Diploma (Elementary) No. of Years Completed (Elementary) Did you Graduate? (Elementary)YesNoOTHER Name and Location of School (Other) Course of Study (Other) Degree or Diploma (Other) No. of Years Completed (Other) Did you Graduate? (Other)YesNo MEMBERSHIP IN PROFESSIONAL OR CIVIC ORGANIZATIONS Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.Employment (Job 1) Company Name (1) Job Address (1) Name of Supervisor (1) Company Phone Number State Job Title and Describe Your Work (1)Employed (Month & Year): From - To From (1) To (1)Weekly Pay: Weekly Pay Start (1) Weekly Pay Last (1) Reason For Leaving (1)Employment (Job 2) Company Name (2) Job Address (2) Name of Supervisor (2) Company Phone Number(2) State Job Title and Describe Your Work (2)Employed (Month & Year): From - To From (2) To (2)Weekly Pay: Weekly Pay Start (2) Weekly Pay Last (2) Reason For Leaving (2)Employment (Job 3) Company Name (3) Job Address (3) Name of Supervisor (3) Company Phone Number(3) State Job Title and Describe Your Work (3)Employed (Month & Year): From - To To (3) From (3)Weekly Pay: Weekly Pay Last (3) Weekly Pay Start (3) Reason For Leaving (3)Employment (Job 4) Company Name (4) Job Address (4) Company Phone Number(4) Name of Supervisor (4) State Job Title and Describe Your Work (4)Employed (Month & Year): From - To From (4) To (4)Weekly Pay: Weekly Pay Start (4) Weekly Pay Last (4) Reason For Leaving (4)Employment (Job 5) Company Name (5) Job Address (5) Company Phone Number(5) Name of Supervisor (5) State Job Title and Describe Your Work (5)Employed (Month & Year): From - To From (5) To (5)Weekly Pay: Weekly Pay Start (5) Weekly Pay Last (5) Reason For Leaving (5)We may contact the employers listed above unless you Indicate those you do not want us to contact. DO NOT CONTACT REFERENCES: PLEASE ANSWER ALL QUESTIONS BELOWThe information requested is needed for a legally permissible reason, including, without limitation, national security considerations, a legitimate occupational qualification or business necessity. The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits discrimination on the basis of age with respect to certain individuals. The laws of most States also prohibit some or all of the above types of discrimination as well as some additional types such as discrimination based upon ancestry, marital status or physical or mental handicap or disability. What was your previous address? Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country How long at previous address? How long at present address? Are you over 21 years of age? YesNoIf not, employment is subject to verification of minimum legal age. Sex: MaleFemale Have you ever been bonded?YesNo If Yes, with what employers? Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by a court? YesNo If Yes, describe in full. General Have You Served In the U.S. Armed Forces? Branch Dates Rank at Discharge Type of DischargeThe information provided in this Application of Employment is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in my dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. If you decide to engage an investigative consumer reporting agency to report on my credit and personal history I authorize you to do so. If a report is obtained you must provide, at my request, the name and address of the agency so I may obtain from them the nature and substance of the information contained in the report. Date Signed Please Initial if you agree with the above statement. Do you have a valid Driver's License?YesNo Driver LicensesStateLicense No.TypeExp Date. Driving ExperienceType of Equipment (Van, Tank, Flat, Etc.)Date FromDate ToApprox. No. of Miles (Total)Straight TruckTractor & TrailerBusOther Safe Driving Awards You Now Hold and From Whom? ACCIDENT RECORD FOR THE PAST 3 YEARS AccidentsDatesNature of Accident (Head-on, rear, etc.)FatalitiesInjuriesAccident 1Accident 2Accident 3 TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (Other than parking violations)Location (City and State)DateChargePenaltyAccident 1Accident 2Accident 3 A. Have you ever been denied a license, permit, or privelege to operate a motor vehicle?YesNo B. Has any license, permit, or privilege ever been suspended or revoked?YesNoIF THE ANSWER TO EITHER A OR B IS YES, PLEASE GIVE DETAILS BELOW. Please Explain Full Name*FirstLast Social Security* Date of Birth01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Driver's License # & Issuing State Background Check Address Street Address City State Postal / Zip CodeI understand that, as a condition of my consideration for employment with Fisher59, LLC or as a condition of my continued employment, Fisher59, LLC may obtain a consumer report that includes, but is not limited to, my creditworthiness or similar characteristics, employment history and education background, social security verification, criminal and civil history, personal interviews, workers comp claims, motor vehicle/OMV records, military records, any other public records and any other information bearing on my credit standing, credit capacity, character, general reputation, personal characteristics and trustworthiness. I understand that this authorizes a pre-screening background investigation and will remain on file and serve as an ongoing authorization for Fisher59, LLC at any time during my affiliation or employment period. For Commercial Driver License holders, I give my consent to Fisher59, LLC to conduct a query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the clearinghouse. I understand that this consent is for multiple limited queries that will be conducted for the duration of employment. I understand that Fisher59, LLC will utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.By initialing and dating below, I am giving my permission to Fisher59, LLC or its agents to perform any of the aforementioned checks. Today's Date InitialsBy initialing and submitting this document, you are agreeing to the terms and conditions. CA, MN, or OK RESIDEENTS ONLY: As part of a routine background investigation, we may request a consumer credit report from a consumer credit reporting agency or one of its associated companies. If we do so and you wish them to send you a free copy of this consumer credit report, Please CheckSubmitReset