Date * Last Name First Name M.I. Home Address City State Zip Home Phone Cell Phone
I am 18 years of age or older. Have you ever applied with Balance, Inc. before? Yes No Have you ever worked with Balance, Inc. before? Yes No How did you learn of Balance, Inc. and/or this position? Are there any days or hours that you would be unable or unwilling to volunteer? Yes No
High School Location Graduate? Yes No Vocational Courses? College/Trade School Location Graduate? Yes No Field of Study Are you planning to pursue further studies? Yes No Topic List any other specialized training Would you be willing to perform all of the tasks required by the position you are applying for? Yes No If not explain which tasks Will you abide by the safety rules of Balance, Inc.? Yes No How many days of work or school have you missed in the last two years? How many times have you been late for work or school in the last two years? Have you ever been disciplined or received verbal or written warnings for absenteeism or tardiness? Yes No If yes, explain Are you presently employed? Yes No If yes, may we contact your employer? Yes No Current Employer Contact Number Have you ever been fired or asked to resign from a job? Yes No If yes, explain References
Give three references, not relatives or former employers
Name Address Phone: (___)___-____ Relationship Name Address Phone (___)___-____ Relationship Name Address Phone (___)___-____ Relationship
I certify that my answers to the foregoing questions are true are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am accepted, any false, misleading or otherwise incorrect statements made on this application form or during any interviews may be grounds for may immediate discharge.
I hereby authorize Balance, Inc. to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements.
I agree that, if I volunteer, I will abide by all the rules and regulations of Balance, Inc. I understand that the taking of drug and alcohol tests, when given pursuant to organization policy, are a condition of continued involvement and refusal to take such tests when asked will be grounds for immediate termination. I also understand that my employment is “at-will” and may be terminated by myself or by the organization at any time for any reason or no reason at all, with or without prior notice.
I have read the above statement and agree to the terms. Legal Name (Signature) Date