Application for Employment
Employee First Name: | Employee Last Name:
New or Rehire: | Hired or Backup: | Location:
Client: | Position Type:
Regular Pay Rate (per hour): | Overtime Pay Rate (per hour):
Permanent or Temporary: | Full- or Part-Time: | Pay Form:
Employee will be employed at Republic Services:
Last Name: | First Name: Middle Initial:
Phone Number: | Email:
Date of Birth: | Social Security:
High School Name & Location: | Years Attended: Graduate? Subjects Studied:
College/Trade School/Military Name & Location: | Years attended: Graduate? | Subjects Studied:
**(Starting with the most recent position, list of last three employers)**
1 | Dates employed: | Name & Address of Employer: Position: | Reason for Leaving:
2 | Dates employed: | Name & Address of Employer: Position: Reason for Leaving:
3 | Dates employed: | Name & Address of Employer: Position: Reason for Leaving:
(List three persons you have known at least one year and are not related to you)
1 | Name: | Business: Address: Years Known:
2| Name: | Business: Address: Years Known:
3| Name: | Business: Address: Years Known:
AUTHORIZATION, WAIVER AND ELECTRONIC SIGNATURE CONSENT
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 agree that I will not commence any action or lawsuit relating to my employment or application for employment with National Star Services and its affiliates more than 6 months after the employment action that is the subject of the action or lawsuit, and I agree to waive any statute of limitations to the contrary. I understand that this means that even if the law would give me the right to wait a longer time to make a claim, I am freely and knowingly waiving that right, and that any claims not brought within 6 months after the relevant employment action will be barred.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information 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 forgoing, 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 also agree that by using an e-signature feature, I am applying my electronic signature, which is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I also agree that no certification authority or other third party verification is necessary to validate my e-signature.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Application for Employment
Agree & Sign