RELO INFORMATION MANAGEMENT, INC. EMPLOYMENT APPLICATION Name:____________________
Revision: 100107
An equal opportunity employer
Referred by
Current Date:
**
**
INSTRUCTIONS: PRINT IN INK. Answer each question completely. Date Available to Work:
.
All information will be held in confidence. If employed, this will become a part of your permanent record.
Name:
LAST
FIRST
MIDDLE
Present
Address:
. Phone No.
City:
State: Zip:
If hired, can you furnish proof that you are legally entitled to work in the U.S.? [ ]
YES [ ] NO
Any relatives now employed by this company: [ ] Yes [ ] No
(If Yes list WHO and relationship) .
Position Applying for: 1) . .
2) . . Salary Desired: . .
List Skills, Training and Qualifications that would qualify you for the position(s) applied for?
.
.
EMPLOYMENT HISTORY: (Beginning with your most recent job and accounting for the
past ten (10) years
of employment, including
all jobs - full time, part time, short term employment, self-employment and military service.)
.
.
Date Employed Month/Year.
.
.
FROM:
(Employer Name)
(Position)
To:
. . Reason for Leaving:
(Address)
(City)
(State) (ZIP)
Point of Contact:
Phone No:
.
.
FROM:
(Employer Name)
(Position)
To:
. . Reason for Leaving:
(Address)
(City)
(State) (ZIP)
Point of Contact:
Phone No:
.
.
FROM:
(Employer Name)
(Position)
To:
. . Reason for Leaving:
(Address)
(City)
(State) (ZIP)
Point of Contact:
Phone No:
(Use Back Side of this application page to further describe employment history as needed.)
RELO INFORMATION MANAGEMENT, INC. EMPLOYMENT APPLICATION Name:____________________
Revision: 100107
Education
Circle highest grade completed in school:
1 2 3 4 5 6 7 8
1 2 3 4
1 2 3 4 5 6 7 8
ELEMENTRY
HIGH
COLLEGE
Name of last school attended
City
Date left school
City/State/Zip
Courses of Study and date Degree(s) received:
PERSONAL REFERENCES:
.
NAME
ADDRESS
.
PHONE NUMBER
FAX NUMBER
LENGTH OF RELATIONSHIP
.
NAME
ADDRESS
.
PHONE NUMBER
FAX NUMBER
LENGTH OF RELATIONSHIP
Personal (optional)
Do you have the ability to perform job-related functions of the position(s) applied for? [ ] Yes [ ] No
If no, describe how you will be able to do the job-related functions:
.
Have you signed any agreement that includes any provisions that could either prohibit employment with the company or
restrict the terms and conditions of employment with the Company? [ ] Yes [ ] No
(If Yes, describe)
.
Have you been convicted of a crime or court martial within the past seven (7) years? [ ] Yes [ ] No
(If Yes, describe)
.
Will you be able to work?
[ ] Full Time [ ] Part Time [ ] Any Shift [ ] Any Day of the Week [ ] Out of Town [ ] Overtime
List Hobbies and Interests:
.
May we contact your present employer?
[ ] Yes [ ] No.
If no, explain.
I hereby certify that the information contained in this application was completed by me and all entries are true and correct and
there are no willful misrepresentation in, omissions or falsifications of the above statements and answers. I am aware that should
an investigation disclose misrepresentation, omissions or falsifications such disclosures will constitute grounds for immediate
dismissal if I am employed by the Company and will automatically bar me from employment with the Company if I am not at the
time an employee of the Company.
I acknowledge and agree that any employment with this Company will be of an "at will nature" and will continue at the will of the
Company and myself and may be terminated at any time for any reason by either party.
SIGNATURE. . DATE. .
(Use Back Side of this application page to further describe criminal or court martial history as needed.)
RELO INFORMATION MANAGEMENT, INC. EMPLOYMENT APPLICATION Name:____________________
Revision: 100107
SUBSTANCE ABUSE TESTING POLICY
On this day, the Relo Information Management, Inc. Substance Abuse Testing Policy is provided to me as described herein. At Relo
Information Management, Inc. substance abuse testing is conducted on all new hire job applicants. Consistent with the policy and the
requirements set forth with the National Association of Information Destruction, Inc. and/or as required by contractual agreements, I
have been requested by the Company to submit to a screening test for illegal drugs, illegally used legal drugs and/or alcohol which
includes the collection of blood, urine and/or breath samples and other necessary medical tests to determine the presence or use of
alcohol, drugs or controlled substances. I also understand that in the event I become a Relo Information Management, Inc. employee, I
may be subject to future for cause and random testing.
I hereby voluntarily consent to provide samples of blood, urine, and/or breath at laboratories designated by Relo Information
Management, Inc. I consent to having specimens tested at the selected laboratories. Further, I certify that the specimen collected from
me will be mine and will not be adulterated or altered in any manner.
The tests will be used to detect the presence of the illegal substances, in addition to other substances for which Relo Information
Management, Inc. may be required to test for under Federal or State law or contractual agreement.
I understand that all screening tests for drugs will be subject to careful testing procedures with mandatory confirmation of any
preliminary positive tests. I further understand that if my test indicates a confirmed positive for illegal drugs, I will be given
reasonable opportunity to explain. If requested, explanation of a confirmed positive test for substances other than illegal drugs will be
provided in a confidential setting. If I provide an unacceptable explanation, I will be denied employment.
I understand that if I become a Relo Information Management, Inc. employee and subject to future for cause and random testing, as an
employee I would have the right to request, to explain in a confidential setting, a positive test result. If the employee requests, in
writing, an opportunity to explain the positive test result within 10 working days after the employee is notified of the test result, Relo
Information Management, Inc. will provide an opportunity, in a confidential setting, within 72 hours after receiving the employee's
written notice, or before taking adverse employment action.
I understand I have the right, at my request, to obtain the written test results and that Relo Information Management, Inc. will provide
written test results to me within five working days after receiving a written request to do so, so long as the written request is made
within six months after the date of the test. In addition, I have the right to a confirmatory drug test to be reviewed by a licensed
physician or doctor of osteopathy after an initial positive drug test result in accordance with AS 23.10.640(d).
I understand the results of these tests and other relevant medical information may be used for employment decisions and will remain
strictly confidential. I hereby authorize the designated laboratory to release results to Relo Information Management, Inc.'s Manager
Human Resources. I further agree to hold Relo Information Management, Inc., its agents, officers and employees harmless from, and
waive all claims existing and future for any, and all liability (including negligence) arising in connection with the testing for drugs
and/or alcohol.
AGREED TO: _______________________________
WITNESS: ___________________________________
Signature
I understand that if I refuse to submit to substance abuse testing, I will not be eligible for employment.
REFUSED: __________________________________
WITNESS: ___________________________________
Signature
___________________________________________________
_____________________________
Printed Name
Date
REASONS FOR REFUSAL: ______________________________________________________________________________
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