Employment Application

Your contact information

How were you referred to us? *

Position applied for *

Full name *

Email *

Phone number *

Mobile / pager / other

Street address *

City *

State *

ZIP code *

Eligibility

Sensitive details (date of birth, SSN) are encrypted at rest and sent only to our office.

Are you 18 years of age or older? *

Yes No

Date of birth *

Social Security Number *

Type of employment desired *

Date available to start *

Salary requirements *

Disclose any aliases / other name(s) used and Social Security Number(s) *

Work history & legal

Have you ever worked for this company? *

Yes No

If yes, when?

Are you legally allowed to work in the United States? *

Yes No

Have you been convicted of a crime (excluding minor traffic offenses)? *

Yes No

If yes, disclose dates and details

Have you ever been placed on the Employee Disqualification List (EDL)? *

Yes No

If yes, disclose dates and details

Background consents

Answering “yes” does not constitute an automatic rejection for employment.

I consent to a closed records check *

Yes No

I consent to a pre-employment criminal record check *

Yes No

Driver’s license number (if applicable)

License state

Education

High school: name & location *

Did you graduate (high school)? *

Yes No

College: name & location

College: years attended

Degrees completed

Other subjects studied

Trade / business / correspondence school

Trade school: years attended

Trade school: subjects studied

Did you graduate (trade)?

Yes No

Skills & qualifications

Summarize your special skills or qualifications *

Employment history

List your most recent employer first. The first is required; the others are optional.

Employer 1 *

Dates of employment (from) *

Dates of employment (to) *

Position(s) held *

Company name *

Address *

City *

State *

ZIP code *

Phone number *

Supervisor *

Supervisor title *

Starting salary *

Ending salary *

Reason for leaving *

Responsibilities *

May we contact this employer for a reference? *

Yes No

Employer 2 (optional)

Dates of employment (from)

Dates of employment (to)

Position(s) held

Company name

Address

City

State

ZIP code

Phone number

Supervisor

Supervisor title

Starting salary

Ending salary

Reason for leaving

Responsibilities

May we contact this employer for a reference?

Yes No

Employer 3 (optional)

Dates of employment (from)

Dates of employment (to)

Position(s) held

Company name

Address

City

State

ZIP code

Phone number

Supervisor

Supervisor title

Starting salary

Ending salary

Reason for leaving

Responsibilities

May we contact this employer for a reference?

Yes No

Final details & signature

Have you used any aliases or SSNs other than those provided above? *

Yes No

If yes, disclose all aliases and Social Security Numbers used

Attach résumé (optional; PDF, DOC, or DOCX, max 5 MB)

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I have read and agree to the certification above. *

Signature *

Date *

I consent to be contacted about my application. See our Privacy Policy. *

Home

Careers

Apply

Careers

Join the Ambiance Team

Our Office

Get in Touch

Service Area