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Applicant Information

Last Name:
First Name:
Middle Initial:
Today's Date:
Address:
City:
State:
ZIP Code:
Telephone No:
Email:
Date of Birth:
Social Security No:
DL/ID No:
Issuing State:

Emergency Contacts

Full Name:
Relationship:
Telephone No:

Military Service

Branch:
Dates From:
To:
Rank at Discharge:

Education

Highest Level of Education Completed & School's Name:

Referral Source

How did you hear about us?:

Have you previously worked for OBR?:
YESNO
If yes, when?:

Position Information

Position Applying For:
Date Available to Start:
Expected Pay Rate:
Years of CT Experience:
Are you authorized to work in the United States on an unrestricted basis? YESNO
List any specific skills, qualifications, or knowledge you have regarding this position, including safety training:

Have you plead “guilty”, “no contest”, or been convicted of a crime in the past seven (7) years? Convictions will not necessarily disqualify an applicant from employment:YESNO
If yes, please explain:
If offered a position with OBR, you will undergo pre-employment screening that includes a drug screen and background check. Drug screening could include a urinalysis and hair follicle test at any point in time of employment. Do you consent? YESNO

Employment History

Employer 1:
Dates Employed:
To:
Supervisor Name & Phone:
Job Title:
Hourly Wages:
Reason for Leaving?

Employer 2:
Dates Employed:
To:
Supervisor Name & Phone:
Job Title:
Hourly Wages:
Reason for Leaving?

Verification Statement

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the facts set forth in this application and release the Employer from any liability.

I acknowledge and understand that the company is an “at will” employer. Therefore, any employee may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party.
Employee Signature:
Date: