Job Opportunities at Brickyard Auto Parts

First Name*

Last Name*

Email Address*

Phone Number*

Referred By

Position Desired

Are You Currently Employed?

Yes

If Applicable, May We Inquire of Your Present Employer?

Yes

Have You Applied to Brickyard Before?

Yes

When Did You Apply Before?

High School Name and Location

Did You Graduate High School?

Yes

High School Years Attended

College Name and Location

Did You Graduate College?

Yes

College Years Attended

College Subjects Studied

Trade, Business, or Correspondence School

Did You Graduate Trade, Business, or Correspondence School?

Yes

Trade, Business, or Correspondence School Years Attended

Trade, Business, or Correspondence School Subjects Studied

Subject of Special Study/Research Work

Special Training

US Military Service

US Military Rank

Have you even been convicted of a felony?

Yes

If Yes, please explain:

Employment History

In the section below, please provide information for your previous 3 employers.

Employer 1 Start Date

Employer 1 End Date

Employer 1 Title

Employer 1 Salary

Employer 1 Reason for Leaving

Employer 1 Address

Employer 1 Phone Number

Employer 2 Start Date

Employer 2 End Date

Employer 2 Title

Employer 2 Salary

Employer 2 Reason for Leaving

Employer 2 Address

Employer 2 Phone Number

Employer 3 Start Date

Employer 3 End Date

Employer 3 Title

Employer 3 Salary

Employer 3 Reason for Leaving

Employer 3 Address

Employer 3 Phone Number

References

In the section below, please provide 3 references that we can contact. Please do not include family members, or anyone you have known for less than a year.

Reference 1 Name

Reference 1 Address

Reference 1 Phone Number

Reference 1 Employer

Reference 1 Years Known

Reference 2 Name

Reference 2 Address

Reference 2 Phone Number

Reference 2 Employer

Reference 2 Years Known

Reference 3 Name

Reference 3 Address

Reference 3 Phone Number

Reference 3 Employer

Reference 3 Years Known

Authorization

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 in formation 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 understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.” In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Date Completed*

Electronic Signature*

Employment at Brickyard Auto Parts

Education History

General Information

Employment History

References

Authorization