INSTRUCTIONS:

PLEASE COMPLETE IN FULL.

Answers provided must be true and complete to the best of your knowledge. Ensure that you have read and signed the acknowledgment.

This application is not intended to be a contract of employment.

We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law.Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.

Position Applying for:
Personal Data
Name:
Permanent Address:
Mailing:
Phone Cell:
Alternate:
Email:
Are you legally eligible to work in the United States?

YesNo
Can you submit proof of legal employment authorization & Identity?

YesNo
Have you ever been convicted of a Felony?

YesNo
If yes, nature and date of offense:
Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?

YesNo
If No, please explain:


Have you ever been discharged or requested to resign?

YesNo
If Yes, please explain:


Have you ever been in the Armed Forces?

YesNo
Specialty:
Date Entered:
Discharge:
Education and Training
Highschool/GED
Name & location of institution


Number of yrs completed


Field of Study


Grade/Diploma/Degree & year completed**


Commercial, Trade or Techinical Training
Name & location of institution


Number of yrs completed


Field of Study


Grade/Diploma/Degree & year completed**


Undergraduate College/University
Name & location of institution


Number of yrs completed


Field of Study


Grade/Diploma/Degree & year completed**


Graduate/Professional
Name & location of institution


Number of yrs completed


Field of Study


Grade/Diploma/Degree & year completed**


Other Continuing Education
Name & location of institution


Number of yrs completed


Field of Study


Grade/Diploma/Degree & year completed**


Professional Qualifications/Memberships/Licenses ** if applicable


** Please provide a copy of the most recent transcript, certificate, and relevant documents.
Specialized Skills
A. Office & Computer

PCMACIPadIPhone/SmartphoneMicrosoft OfficeAdobe Design SoftwareManagement/SalesOther
B. Language(s):
Spoken:
Written:
C. Technical:
D. Trades/Skills:
E. If you are applying for a position requiring a Driver's License, please complete the following:
Do you have a valid driver's license?

YesNo
Class:
State:
Moving violations or accidents in the past 3 years?

YesNo
If yes, please describe:


Previous Employment
Name of Employer:


Address:


Last Position Held:


Phone:


Name of Supervisor:


Reason for Leaving:


Period Employed:


Starting & Final Salary:


Duties:


Name of Employer:


Address:


Last Position Held:


Phone:


Name of Supervisor:


Reason for Leaving:


Period Employed:


Starting & Final Salary:


Duties:


Name of Employer:


Address:


Last Position Held:


Phone:


Name of Supervisor:


Reason for Leaving:


Period Employed:


Starting & Final Salary:


Duties:


Other
Please use this space below to elaborate any additional relevant skills, education, training, previous employment, special achievements, job interests, volunteer work, hobbies or any new/different information that you feel should be considered.


References
List three individuals, at least 21 years of age or older and not considered relatives or personal friends, who observed or experienced first hand your work style, habits and performance. Examples might include a coordinator of your volunteer efforts, college professor, pastor/faith community leader, or former coworker.
Name


Company


Position


Phone/Email or Address


Name


Company


Position


Phone/Email or Address


Name


Company


Position


Phone/Email or Address


May we contact.....
Your Present Employer?

YesNo

If No, please clarify below:
Your Previous Employer?

YesNo

If No, please clarify below:
Explaination:


Acknowledgement and Declaration:
I certify that I have personallyt completed this application. I understand and agree that Centerline Supply may at any time seek verification of the above and further information in considering my suitability for the current, or any future, position. I hereby request and authorize anyone approached by Centerline Supply its employees and/or agents, to provide them with any and all information requested to the best of their ability. I hereby release Centerline Supply its employees and agents, and anyone providing information pursuant to a request from Centerline Supply to provide information about me, from any and all claims whatsoever which may arise as a result of the release of such information. I understand and agree that any omission, false or misleading statement may disqualify me from employment, or result in dismissal. A photographic copy of this authorization shall be as valid as the original. I understand the nature of the position for which I am applying and certify that I am able to perform its essential functions as outlined. I understand that employment is at will and Centerline Supply may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I understand that as a condition of mycontinued employment Centerline Supply may, form time to time, require me to submit specimens of blood, urine, and other bodily fluids for testing to determine the presence of alcohol and/or controlled substances. I understand that if offered a position with Centerline Supply, I may be required to submit to a pre-employment examination, drug screening and background check as a condition of employment. I understand results form, refusal to cooperate with, or any atempt to affect the results of these pre-employment checks may result in withdrawal of any employment offer or termination of employment.
Date


Applicant Signature


Centerline Supply, is committed to the principles of Equal Employment Opportunity and welcomes applications from all qualified candidates. Centerline Supply adheres to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability unrelated to job performance. We assure you that your opportunity for employment with this Company depends solely on your qualifications.
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS APPLICATION AND FOR YOUR INTEREST IN CENTERLINE SUPPLY.