# of Years
Date of Birth (required)
Social Security No. (required)
Telephone Number (required)
Your Email (required)
Have you ever been convicted of a felony? (Y/N)
If you answered yes, please provide explanation:
Are you a U.S. Citizen? (Y/N)
If selected for employment, are you willing to submit to a pre-employment drug screen?? (Y/N)
Must list the complete mailing address: street number and name, city, state and zip code.
Reasons for Leaving
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.
SECOND LAST EMPLOYER
THIRD LAST EMPLOYER
FOURTH LAST EMPLOYER
I authorize Smith Industries to make investigations and inquiries to my personal, employment, financial and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Smith Industries if hired.
I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as may be required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
• Review information provided by current/previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer;
• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.”
All information is to be used in the decision making for employment with Smith Industries.
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.
APPLICANT’S SIGNATURE (Type your full name)