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Application for Employment - Date: ________________________

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color,
age, sex, sexual orientation, religion, handicap, or national origin.

Personal Information
Name:
Last

First

Street

City

Middle

Address:
State

Zip Code

Phone: ____________________ Email: ________________________ Social: ______________________


Are you at least 18 years of age or older?

Yes No

Are you eligible to work in the U.S.?

Yes No

Have you been convicted a crime (excluding traffic tickets) in the past 10 years? Yes No
**A conviction will not necessarily disqualify you from employment

Do you currently have any criminal cases pending against you or are you on probation for a previous
conviction?
Yes No
Yes No

Have you ever been convicted of a felony?


**Please note that a conviction will not necessarily disqualify you from employment

If yes, please explain: __________________________________________________________________


_____________________________________________________________________________________
How were you referred to RideCentric? ____________________________________________________
Employment Desired
Position:

Date Available:

Circle the days you are available to work:

Mon

Salary Desired:
Tue

Wed

Thu

Fri

Sat

Sun

Please list hours you are available? ____________________________________________________


Are you employed now? Yes No If yes, may we inquire of your present employer? Yes No
Ever applied to this company before? Yes No

If yes, when?____________________________

Education
High School:
From:

Address:
To:

College:
From:

Degree:

Address:
To:

Other:
From:

Did you graduate? Yes No

Did you graduate? Yes No

Degree:

Address:
To:

Did you graduate? Yes No

Degree:

General
Please list any specific skills you would bring to the position: __________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Previous Employment
Company:

Phone No.:

Address:

Supervisor:

Job title:

Starting Salary:

Ending Salary:

Responsibilities:
From:
To:
Reason for leaving:
_____________________________________________________________________________________
Company:

Phone No.:

Address:

Supervisor:

Job title:

Starting Salary:

Ending Salary:

Responsibilities:
From:
To:
Reason for leaving:
_____________________________________________________________________________________
Company:

Phone No.:

Address:

Supervisor:

Job title:

Starting Salary:

Ending Salary:

Responsibilities:
From:

To:

Reason for leaving:


References

**List below three references not related to you, whom you have known at least one year.

Name

Phone Number

Position

Years
Acquainted

Authorization to Conduct Pre-Employment Background Screenings


I certify that the facts contained in this application are true and complete to the best of my
knowledge and understand that, if employed; falsified statements on this application shall be
grounds for dismissal.
I authorize investigation of all statements contained herein and the reference and
employers listed above to give out any and all information concerning my previous employment
and any pertinent information they may have, personal or otherwise, and release the company
from all liability for any damage that may result from utilization of such information.
I also understand and agree that no representative of the company has any authority to
enter into any agreement for employment for any specified period of time, or to make any
agreement contrary to him forgoing, unless it is in writing and signed by an authorized company
representative.
This waiver does not permit the release of use of disability-related of medical information
in a manner prohibited by the Americans with Disabilities ACT (ADA) and other relevant
federal and state law.
I understand that a criminal record check will be conducted for conviction and
pending criminal case information only and that it will not necessarily disqualify me from
employment. By signing below I authorize RideCentric and or its agents and assigns to
conduct any and all background screenings necessary for employment.

Applicant Signature: _________________________

Date: ________________________