T.L. Hart, Inc. -- Customer Driven for Over 15 Years!

Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap.

As employers/government contractors, we comply with government regulations and affirmative action responsibilities.

Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the Applicant Data Record. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.

Date:
Position(s) Applied For:
Referral Source:	Advertisement Friend Relative Walk-In Employment Agency Other

Name:	Last: First: Middle:
Telephone:	( )
Address:
City:
State:
Zip Code:

	Affirmative Action Survey Government agencies require reports on the sex, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information is voluntary.
Check one:	Male Female
Check one of the following:	White Black Hispanic American Indian/Alaskan Native Asian/Pacific Islander
Check if any of the following are applicable:	Vietnam Era Veteran Disabled Veteran Handicapped Individual
T.L. Hart, Inc. “An Equal Opportunity/Affirmative Action Employer”
APPLICATION FOR EMPLOYMENT
Today’s Date:
Email Address:
Time:	AM PM
Name:	Last: First: Middle:
Current Address:
City:
State:
Zip Code:
Length of time at this address:
Previous Address:
City:
State:
Zip Code:
Length of time at this address:
Social Security Number:
Telephone :	( )
Do you have a valid Michigan Driver's License?	Yes No
Do you have dependable transportation?	Yes No
How many years have you lived in this city?
Job(s) applied for:	1. Rate of pay expected $ per 2. Rate of pay expected $ per
Do you want to work:	Full-Time Part-Time If applying for part-time, what days and hours?
Have you ever applied for work with us before?	Yes No If yes, when?
List anyone you know who works for us:
Do you have any skills, qualifications or experiences which you feel would be especially fit for work with us?
Are you afraid of heights?	Yes No
Are you willing to work any shift assigned you?	Yes No
U.S. Armed Forces Service?	Yes No If Yes, From: To: Branch of Service: Duties: Rank or rating at time of enlistment: Were you dishonorably discharged? Yes No If yes, explain:
Are you able to do the job(s) for which you are applying?	Yes No If no, explain:
Are you 18 years of age or older?	Yes No
Have you ever been convicted of a crime?	Yes No If yes, explain when, where, and the nature of the offense:
Are there any felony charges pending against you now?	Yes No If yes, describe:
Are you authorized to work in the United States?	Yes No
If hired, when can you start?
EDUCATION
HIGH SCHOOL
School Name:
Dates Attended:
City:
State:
Course:
Graduated:	Yes No
College
School Name:
Dates Attended:
City:
State:
Course:
Graduated:	Yes No
Other
School Name:
Dates Attended:
City:
State:
Course:
Graduated:	Yes No
PRIOR WORK EXPERIENCE (Please list your most recent employment first, use additional space below if necessary to list all prior employers)
Name of Employer 1:
Address:
City:
State:
Zip Code:
Dates of Employment:	From: To:
Type of Work Done:
Starting Pay:
Final Pay:
Reasons for Leaving:

Name of Employer 2:
Address:
City:
State:
Zip Code:
Dates of Employment:	From: To:
Type of Work Done:
Starting Pay:
Final Pay:
Reasons for Leaving:

Name of Employer 3:
Address:
City:
State:
Zip Code:
Dates of Employment:	From: To:
Type of Work Done:
Starting Pay:
Final Pay:
Reasons for Leaving:

Name of Employer 4:
Address:
City:
State:
Zip Code:
Dates of Employment:	From: To:
Type of Work Done:
Starting Pay:
Final Pay:
Reasons for Leaving:
BUSINESS REFERENCES
Reference Name 1:
Address:
City:
State:
Zip Code:
Telephone:	( )
Occupation:

Reference Name 2:
Address:
City:
State:
Zip Code:
Telephone:	( )
Occupation:

Reference Name 3:
Address:
City:
State:
Zip Code:
Telephone:	( )
Occupation:
APPLICANT’S CERTIFICATION AND AGREEMENT *PLEASE READ CAREFULLY:*
1. Certification of Truthfulness. I certify that all statements on this application for Employment are made truthfully and without evasion, and further understand and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed, or if employed may result in my dismissal. 2. Authorization for Employment/Educational Information. I authorize the references listed in this Application for Employment, and any prior employer, educational institution, or any other persons or organizations to give this Company any and all information concerning my previous employment/educational accomplishments, disciplinary information or any other pertinent information they may have personal or otherwise, and release all parties from liability for any damage that may result from furnishing same to you. I hereby waive written notice that employment information is being provided by any person or organization. 3. Employment at Will. If I am hired, in consideration of my employment, I agree to abide by the rules and policies of this Company, including any changes made from time to time, and agree that my employment and compensation can be terminated with or without cause, and with or without notice at any time, at the option of either the Company or myself. I understand that no manager or other representative of the Company, other than the President, has any authority to enter into agreement for employment for specific or indefinite period of time, or to make any agreement contrary to the foregoing. Any such agreement made by the President must be in writing to be effective. 4. Authorization to Work. If I am selected for hire I will be offered employment provided I verify that I am authorized to work as required by the Immigration Reform and Control Act of 1986. 5. Limitation on Claims. I agree that any action or suit against the Company arising out of my employment or termination of employment, including but not limited to claims arising under State or Federal civil rights statutes, must be brought within 180 days of the event giving rise to the claim or be forever barred. I waive any statute of limitations to the contrary. 6. Need for Accommodation. If I am a handicapper who requires an accommodation to perform the job, I must notify the Company of that need within 182 days after I knew or reasonably should have known that an accommodation was needed. Failure to do so will bar me from alleging that the Company has not accommodated me as required by law. 7. Criminal Records Check. I agree to execute an authorization for this employer to secure criminal conviction history from the appropriate law enforcement agency, should the Company determine it is necessary to do so. 8. Release of Medical Information. I authorize every medical doctor, physical or other health care provider to provide any and all information, including but not limited to, all medical reports, laboratory reports, X-rays or clinical abstracts relating to my previous health history or employment in connection with any examination, consultation, test or evaluation. I hereby release every medical doctor, health care personnel and every other person, firm, officer, corporation, association, organization or institution which shall comply with the authorization or request made in this respect from any and all liability. I understand that this release will not be sent to my physician or other health care provider until a job offer has been made. 9. Physical Exam and Drug and Alcohol Testing. I agree to take a physical exam and authorize the Company or its designated agents(s) to withdraw specimen(s) of my blood, urine or hair for chemical analysis. One purpose of this analysis is to determine or exclude the presence of alcohol, drugs or other substances. I understand that decisions concerning my employment will be made as a result of this test. 10. Consideration for Employment. I understand that my application will be considered pursuant to the Company’s normal procedures for a period of thirty (30) days. If I am still interested in employment thereafter, I must reapply. I have read and understand items one through ten above, and acknowledge that by entering my name below.
DISCLOSURE AND CONSENT FAIR CREDIT REPORTING ACT REQUIREMENTS
The Fair Credit Reporting Act “FCRA” is a federal law that requires employers to follow several steps before obtaining a “consumer report” on an employee or applicant. According to the Federal Trade Commission “FTC”, anytime an employer engages an outside agency to investigate, the employer is likely obtaining from that agency a consumer report which triggers the requirements of FCRA. Before an employer engages an outside agency to obtain a consumer report or investigate an employee, the employer must: 1) Provide the employee or applicant with a clear and conspicuous disclosure that a consumer report may be obtained for employment purposes; and 2) Obtain written authorization from the employee or applicant. Credit Report I understand that T.L. HART, INC.,will request a consumer report or an investigative consumer report, including information as to my character, general reputation, personal characteristics and mode of living for general purposes of evaluating my application for employment. I further understand that I may request in writing from the Company a complete and accurate disclosure of the nature and scope of the investigation requested. I consent to the furnishing of such report to the Company.
Date:
Full Name*:
	*Entering name is the same as signing your signature.