Present Address:

SSN#: Driver's License #:

Date of Birth: Marital Status (optional):

Have you applied to this company before? Yes No If yes, when?

What method of transportation will you use to get to work?

Position you are applying for:

Would you work Full Time Part Time Rate of pay expected:

If your application is considered favorably, on what date will you be available to work?

List any friends and/or relatives who are currently working for the Harrison Company:

Name: Position:

Name: Position:

Are there any other experiences, skills, etc. you feel that would especially fit you for work with us? If yes, explain:

RECORD OF EDUCATION

High School: City/State:

Did you graduate? No Yes Diploma:

College: City/State:

Did you graduate? No Yes Diploma:

Course of Study:

Other: City/State:

Did you graduate? No Yes Diploma:

Course of Study:

PERSONAL REFERENCES

(Do not list former employees of The Harrison Company)

Name: Phone #:

Name: Phone #:

Name: Phone #:

PREVIOUS EMPLOYMENT

Name of Business:

City/State: Phone #:

From: To: Weekly Salary:

Describe the work you did:

Reason for leaving:

Supervisor's Name: Phone #:

Name of Business:

City/State: Phone #:

From: To: Weekly Salary:

Describe the work you did:

Reason for leaving:

Supervisor's Name: Phone #:

Name of Business:

City/State: Phone #:

From: To: Weekly Salary:

Describe the work you did:

Reason for leaving:

Supervisor's Name: Phone #:

Attention Applicant: Please read carefully. By clicking the Submit button, you agree to the following:

I hereby declare this information provided by me in this Application for Employment is true, correct, and complete to the best of my knowledge. I understand that if employed, any misstatement or omission of fact on this application shall be considered cause for dismissal. I authorize you to obtain an investigative consumer report containing information obtained through personal interviews with my neighbors and acquaintances. This report, if obtained, may include information as to my character, general reputation and mode of living. I authorize you to contact any or all of my previous employers. I understand I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of any such information. The first ninety (90) days of employment will be an introductory period during which I will become eligible for permanent employment. To be considered for permanent employment, I will be required to take and pass a company physical which includes drug screening.