Application for Employment

Job Position Applied For & ID Number *

APPLICANT'S INFORMATION

Full Name *

First

Middle

Last

Email *

Phone *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number *

Driver's License Number *

Driver’s License State *

Issuance State

Driver’s License Expiration Date *

Exp. Date

Are you at least 18 years old? *

Yes
No

Who referred you to our company?

Do you have any friends or relatives who work here?

Yes
No

If yes, who?

Have you applied to our company previously? *

Yes
No

If yes, when?

Multiple Choice

Full-Time
Monday-Friday
Part-Time
Weekends

If you are offered employment, when would you be available to begin work? *

If hired, are you able to submit proof that you are legally eligible for employment in the United States? *

Yes
No

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation? *

Yes
No

APPLICANT'S EMPLOYMENT HISTORY

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment.

* Employer 1

Employer’s Name: *

Supervisor’s Name: *

First

Last

Work Address: *

Address Line 1

City

State

Zip Code

Primary Job Duties: *

Reason for Leaving: *

Date of Employment *

* Employer 2

Employer’s Name: *

Supervisor’s Name: *

First

Last

Work Address: *

Address Line 1

City

State

Zip Code

Primary Job Duties: *

Reason for Leaving: *

Date of Employment *

* Employer 3

Employer’s Name: *

Supervisor’s Name: *

First

Last

Work Address: *

Address Line 1

City

State

Zip Code

Primary Job Duties: *

Reason for Leaving: *

Date of Employment *

APPLICANT'S EDUCATION AND TRAINING

List your current or most recent education first.

College/University 1

College/University Name:

Address:

Address Line 1

City

State / Province / Region

Postal Code

Did you receive a degree?

Yes
No
Currently in school

If yes, indicate year of graduation and degree(s) received:

If currently in school, expected graduation date and degrees:

College/University 2

College/University Name:

Address:

Address Line 1

City

State / Province / Region

Postal Code

Did you receive a degree?

Yes
No
Currently in school

If yes, indicate year of graduation and degree(s) received:

If currently in school, expected graduation date and degrees:

Other Training (graduate, technical, vocational)

Other Training (graduate, technical, vocational):

Did you complete your program?

Yes
No

If yes, what credential(s) did you receive:

Please indicate any current professional licenses or certifications that you hold

Notable Awards, Honors, Special Achievements:

High School Name and Address

Did you receive a degree?

Yes
No

If yes, what degree(s) did you receive: (copy)

MILITARY SERVICE

Are you a veteran of the US military? *

Yes
No

Branch:

Specialized Training:

ADDITIONAL INFORMATION

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

Additional Information

REFERENCES

List three non-relatives who would be willing to provide a reference for you.

1. Reference Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Only numbers, no dashes or special symbols.

Relationship *

2. Reference Name *

First

Last

Address (copy) *

Address Line 1

City

State

Zip Code

Phone *

Only numbers, no dashes or special symbols.

Relationship *

3. Reference Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Only numbers, no dashes or special symbols.

Relationship *

File Uploads

Please upload your resume and cover letter below, as a PDF or Plain Text files only.

Upload your resume *

Click or drag a file to this area to upload.

PDF or plain text files only

Upload a cover letter *

Click or drag a file to this area to upload.

PDF or plain text files only

CERTIFICATION

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize, Birmingham Technologies, Inc. to perform a background check including but not limited to contacting former employers and educational organizations regarding my employment, education and certifications. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand the relationship will be “at-will” in which either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Birmingham Technologies, Inc., except in a specific written contract of employment signed on behalf of the organization by its CEO, has the power to alter or vary the voluntary nature of the employment relationship.

I have carefully read the above verification and understand and agree to its terms.

Agree to Certification *

Agree
Disagree

By selecting "Agree" using any device, means or action, you consent to the legally binding terms and conditions of this Certification. You further agree that your signature on this document is as valid as if you signed the document in writing.

Applicant's Signature *

First/Middle/Last

Date *

Additional Information

Please complete the application in its entirety. Indicate “N/A” if not applicable.

It is the policy of Birmingham Technologies, Inc. to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.

Job Application

APPLICANT'S INFORMATION

APPLICANT'S EMPLOYMENT HISTORY

* Employer 1

* Employer 2

* Employer 3

APPLICANT'S EDUCATION AND TRAINING

College/University 1

College/University 2

Other Training (graduate, technical, vocational)

MILITARY SERVICE

ADDITIONAL INFORMATION

REFERENCES

File Uploads

CERTIFICATION