CORPORATE OFFICES
7795 UNIVERSITY COURT
WEST CHESTER, OHIO 45069
(513) 793-0900 		EMPLOYMENT APPLICATION
Pump Salon is An Equal Opportunity Employer, committed to employing individuals without regard to race, color, age, sex, marital status, veteran status, religion, creed, national origin, ancestry or handicap. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.

Required fields are marked by this color/hue:

Last Name

First Name

Middle

Address

City

State

Zipcode
Phone (include area code)
()

ex: (111) 2223333

 Email

ex: yourname@somewhere.com

 Position Applied For
 Date Available
Have you ever worked for us before? Yes
No 		(If Yes, give details)
Have you ever applied for a position with us? Yes
No 		(If Yes, give details)
Within the last 10 years, have you been convicted of a felony? Yes
No 		(If Yes, give details)
If under 21, please state age.    
If employed and you are under 18, can you furnish a work permit? Yes
No 		 
Do you have the legal right to be and work in this country? Yes
No 		(If No, give details)
What prompted you to apply here?    
Are you seeking full-time part-time temporary or summer employment?    
Salary Desired    
Are you now or do you expect to be engaged in any other business or employment? Yes
No 		 
Are there any days or hours you would be unable or unwilling to work? Yes
No 		(If Yes, please specify those days or hours you would be unable or unwilling to work)
EDUCATION
INSTITUTUTIONS NAME
INSTITUTIONS ADDRESS
MAJOR FIELD OF STUDY
DID YOU GRADUATE?
High School
 
N/A
Yes
No
Degree Rec'd
College or University
Yes
No
Degree Rec'd
Trade or Business School
Yes
No
Degree Rec'd
Other
Yes
No
Degree Rec'd

Notice: The Fair Credit Reporting Act (Public Law 91-508) requires that we notify you that a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request within a reasonable period of time, additional information as to the nature and scope of the report, if one is made, will be provided.

EMPLOYMENT RECORD: Please list all employment starting with the most recent. Account for all periods including U.S. Armed Forces, Periods of unemployment, and voluntary services.
LIST YOUR MOST RECENT POSITION HELD MAY WE CONTACT YOUR PRESENT EMPLOYER? Yes No


Employers Name, Complete address, and Phone No.
DATES EMPLOYED
  
From To Position Title
SALARY
 Name and Title Of Supervisor
Start Final Reason for Leaving
Employers Name, Complete address, and Phone No.
DATES EMPLOYED
  
From To Position Title
SALARY
 Name and Title Of Supervisor
Start Final Reason for Leaving
Employers Name, Complete address, and Phone No.
DATES EMPLOYED
  
From To Position Title
SALARY
 Name and Title Of Supervisor
Start Final Reason for Leaving
Employers Name, Complete address, and Phone No.
DATES EMPLOYED
 
From To Position Title
SALARY
Name and Title Of Supervisor
Start Final Reason for Leaving


Additional Comments
Professional References (Do Not Use Relatives)
Name
Company Name & Address
Telephone No.
Occupation
Years Known

PRE EMPLOYMENT STATEMENT

I understand that in processing this employment application, the Company may request that an investigative consumer's report be prepared which will provide applicable information concerning character and general reputation. Upon written request, information as to the nature and scope of the report, if one is made, will be provided to me. I certify that to the best of my knowledge the foregoing statements given by me are true. I understand that if I am employed, any misrepresentation or omission by me herein will be sufficient cause for dismissal from the service of the Company.

I authorize any investigation of the above information for the purpose of verification. Because of the nature of the employment, any investigation may include, but may not be limited to, former employment and employers, educational institutions, and criminal records.

I understand that employment is subject to my ability to obtain any required permits, health cards or approvals from any appropriate state, local or federal agency.

I authorize the Butler County, Hamilton County or Warren County Sheriff Office to release information regarding any Traffic or Criminal convictions that I have on file. If it is necessary to verify this Authorization, I can be contacted at the above telephone number. This Authorization is void if not exercised by the person or organization named on the top of this application within (1) year from the date submitted. I hereby agree to indemnify the applicable County and the County Sheriff and his representatives for any liability arising out of the improper use of the information provided.

I agree

We, Pump Salon, certify that the information applied for will be used only for the purpose for which it is requested and agree that this information will immediately be destroyed after use or if retained, not released outside this agency.