Employee Service Technician Form

EMPLOYEE SERVICE TECHNICIAN FORM

Personal Information

Position Information

Full-time    Part-time    Temporary / Seasonal    Contract

Certifications, Licenses & Skills

Driver's License Number: Issuing State:

ASE Certified    EPA Certified    Manufacturer-trained technician    Other

Employment History

Employer 1

Employer 2

Education & Training

Professional References

Safety, Health & Physical Capability

Can you perform essential job functions with or without reasonable accommodation? Yes    Yes, with accommodation    No

Safety training completed: OSHA-compliant safety training    Company safety orientation    Date last safety training:

Authorization & Legal Acknowledgements

Background checks, drug screening and verification: By signing below I expressly authorize the employer to obtain consumer reports, criminal history and motor vehicle records as applicable to my duties, and to require pre-employment drug/alcohol screening where permitted by law. I further authorize prior employers and listed references to release employment-related information to the employer. I understand that any offer of employment may be conditioned on the results of these checks and screenings.

Certification of truthfulness: I certify that all statements on this form are true, accurate and complete to the best of my knowledge. I acknowledge that any material misrepresentation, omission, or falsification may be grounds for refusal to hire or, if hired, termination of employment.

At-will employment: If employed, I understand that my employment is at-will and may be terminated by either party at any time, with or without cause and with or without prior notice, unless otherwise specified in a signed written agreement.

Equal employment opportunity: The employer is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or other protected status as required by applicable law.

Consent to contact prior employers and references: I authorize the employer and its agents to contact former employers, references and educational institutions to verify the information provided and to obtain any other information relevant to my application.

Background check consent: I understand that the scope of any background investigation may include, but is not limited to, verification of social security number, criminal history, civil records, employment history, education, driving record, and professional licensure status where relevant to the position.

I authorize investigation of all statements contained in this form and acknowledge the certification and acknowledgements above.

Emergency Contact

Applicant Certification

I certify under penalty of perjury that the information provided on this form is true, correct and complete. I understand that false statements or omissions may result in denial of employment or termination if employed. I also agree to comply with all company policies, safety rules and lawful directives while performing my duties.

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