Full Name*

Phone *

Address *

City, State *

ZIP Code *

Are you 18 years or older? *

Yes

No

Have you ever applied before? *

Yes

No

If yes, when?

Are you currently employed? *

Yes

No

If yes, may we contact your employer?

Yes

No

Name and Phone Number of current employer

Are you currently on layoff status? *

Yes

No

When are you available to start?

Do you have a commercial driver's license? *

Yes

No

Have you been convicted of a felony in the last 7 years? *

Yes

No

Highest Level of education achieved *

Name/Location of School *

Course of Study / Degrees Earned *

Secondary Languages *

Please list any specialized skills, certifications, or qualifications you poses

Mid-Tec is proud to be an equal opportunity employer. We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.

Starting with your current or most recent employer, list your past three employers and give us information about the job you held. If self-employed, please describe the business and provide a business refernce under "Supervisor's Name". By listing this information below, you understand that we may contact your former employers or supervisors for references.

Name of Employer

Start Date

End Date

Address

Starting Wage

Ending Wage

Phone Number

Supervisor's Name

Job Title

Reason for leaving

Name of Employer

Start Date

End Date

Address

Starting Wage

Ending Wage

Phone Number

Supervisor's Name

Job Title

Reason for leaving

Name of Employer

Start Date

End Date

Address

Starting Wage

Ending Wage

Phone Number

Supervisor's Name

Job Title

Reason for Leaving

Name

Phone

Name

Phone

Name

Phone

Application Statement

I certify that all inforation I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public angencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims i may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using such information inthe employment process and all other persons, corporations or organizations for fusnishing such information about me.

I understand that the empoyer does not unlawfully discriminate in employement and no question on this application is used for the purpose of limiting or excusing any applicatn from consideration for employoment on a basis prohibited by applicable local, state, or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if i have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill our a new application.

If I am hried hired, I understand that i am free to resign at any time, with or without cause and without prior notice, and the employer reserver the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not consitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary adn that no implied, oral, or written agreements contrary to foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete a Form I-9 in this regard.

Candidate eSignature *

Candidate eSignature Date *