EPRINE COMMUNITY SERVICES

Personal Information
Last Name*
First Name*
Middle Initial
Address*
Street Address City State ZIP Code
Home Phone Number
Cell Phone Number*
Email*

References
Include only individuals familiar with your work ability. Do not include relatives or names of supervisors listed.
Reference 1: Name*
Reference 1: Address/Phone*
Reference 1: Years Known/Relationship*
Reference 2: Name*
Reference 2: Address/Phone*
Reference 2: Years Known/Relationship*
Reference 3: Name
Reference 3: Address/Phone
Reference 3: Years Known/Relationship

Education
If your school records are under a different name than listed on page 1, please enter that name:
High School
Name and Address of School
Course of Study
Years Completed
- 9
- 10
- 11
- 12
Diploma/Degree
College
Name and Address of School
Course of Study
Years Completed
- 1
- 2
- 3
- 4
Diploma/Degree
Graduate/Professional Trade/Business School
Name and Address of School
Course of Study
Years Completed
Diploma/Degree
Military Service
Branch
Start Date of Service
Discharge Date

Employment Experience
Have you ever been dismissed, involuntarily terminated or forced to resign from employment?*
- Yes
- No
If yes, please explain in detail:
Previous Employers
Provide complete information on your last three employers.

PLEASE NOTE: Your application may not be considered unless every question in this section is answered. Since we will make every effort to contact former employers, the correct telephone numbers of past employers are critical. Ask for a phone book or call information if necessary. FOR EMPLOYERS OUTSIDE THE U.S., A CURRENT FAX NUMBER IS MANDATORY.
Most Recent Employer
Are you currently working for this employer?
- Yes
- No
If so, may we contact?
- Yes
- No
Phone
Fax
Company Name
City
State
Dates Employed – From/To:
Job Title
Supervisor Name
Duties
Reason for leaving
Second Most Recent Employer
Phone
Fax
Company Name
City
State
Dates Employed – From/To:
Job Title
Supervisor Name
Duties
Reason for leaving
Third Most Recent Employer
Phone
Fax
Company Name
City
State
Dates Employed – From/To:
Job Title
Supervisor Name
Duties
Reason for leaving

Driver's License Information
If the job requires, do you have the appropriate valid driver’s license?
- Yes
- No
Name on Driver's License
DL#
Type
State of Issue
Have you had any moving violations within the last seven years?
- Yes
- No
If Yes, please describe:

Applicant Note
This application form is intended for use in evaluating your qualifications for employment. This application form is not an offer of employment. If hired, such employment shall be considered “at-will,” and this application is not intended to constitute a contract of continued employment. False or misleading statements during the interview or on this form may result in the refusal to hire or termination of employment. Applicants are considered for positions without discrimination to race, color, religion, sex, national origin, age, disability, or any other consideration made unlawful by applicable federal, state, or local laws. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment and prior to reporting to work, you may be required to submit to a medical review. Depending on the company policy and the needs of the job, you may be required to complete a medical history form and may be required to be examined by a medical professional designated by the company. Smoking is prohibited in all indoor areas and the Company’s facilities.
PERMISSION TO WORK IN THE UNITED STATES
Are you legally eligible to work in the United States?*
- Yes
- No
Proof of employment eligibility will be required if hired.
CERTIFICATION AND RELEASE
I certify that I have read and understood the applicant’s note on this form and that I give the answers to the above questions and the statements made by me are complete and accurate to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I release all former employers, persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
Signature
Date
MM slash DD slash YYYY

APPLICANT’S AGREEMENT AND CERTIFICATION
I certify that the answers given in this application are accurate to the best of my knowledge. I understand that the use of this application form does not indicate that there are any positions open and does not in any way obligate Eprine. I understand that should I be granted an interview, no representations that may be made at the interview are to be construed as creating any obligation, promise, or contract on behalf of Eprine. Further, in consideration of my employment, I agree to conform to the policies and procedures of Eprine, as they may from time to time be implemented or revised I understand that false or misleading information given in my application, resumes, interview(s), or during my employment may result in withdrawal of a job offer or corrective actions up to and including termination of employment, whenever the omission or falsehood is discovered. I understand that Eprine may require Direct Deposit of my paycheck into a bank account. I understand that acceptance for employment shall depend on satisfactory replies from my references and other background checks. In the event I receive a job offer, I also understand that I may be subject to a criminal background check, based on the position I am applying for and may be subject to a medical examination that I must pass before I commence work. I have read, understood, and agreed to these terms.
Signature
Date
MM slash DD slash YYYY

AUTHORIZATION TO COLLECT BACKGROUND INFORMATION
I have applied for employment with Eprine. I authorize investigation of all statements contained in this application for employment as may be necessary for arriving at an employment decision. I authorize representatives of Eprine to obtain pertinent information from my previous employers, references, and other persons with knowledge of my work history and background, financial history, education, regulatory or police records, driving records, licensing status or professional designation, and character or reputation, and to consider the information provided by the background check when making decisions regarding my application, and if hired, my employment. I authorize all previous employers, references, or other persons having knowledge of my record or myself to release such information to Eprine and hereby release all persons from liability for any damage that may result from furnishing such information to Eprine. A photocopy of this authorization may be accepted in lieu of the original.
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Signature
Date
MM slash DD slash YYYY

Covid-19 Information

Job Application – English

Job Application – English

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Personal Information

Employment Desired

Job-related Skills

Professional Licenses and Certifications

References

Education

High School

College

Graduate/Professional Trade/Business School

Military Service

Employment Experience

Previous Employers

Most Recent Employer

Second Most Recent Employer

Third Most Recent Employer

Driver's License Information

Applicant Note

PERMISSION TO WORK IN THE UNITED STATES

CERTIFICATION AND RELEASE

APPLICANT’S AGREEMENT AND CERTIFICATION

AUTHORIZATION TO COLLECT BACKGROUND INFORMATION

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