Stom Painters

Todays Date ( mm/dd/yy ):

Last Name:

First Name:

Middle Initial:

10 Digit Phone Number:

Email Address:

Present Address:

Permanent Address:

City:

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Country: Select Country United States United Kingdom Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and The South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

State: Select a State N/A Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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ID #:

Position Title:

Desired Wage:

Date you can start ( mm/dd/yy ):

Currently Employed: Yes  No 

May we contact your present employer?: Yes  No 

Have you ever applied here before?: Yes  No 

If so, when?:

School Name / Location:

Dates (yymm - yymm):

Graduated? (Y / N):

Subjects Taken:

School Name / Location:

Dates (yymm - yymm):

Graduated? (Y / N):

Subjects Taken:

School Name / Location:

Dates (yymm - yymm):

Graduated? (Y / N):

Subjects Taken:

U.S. Military or Naval Service:

Special Skills or Training:

Special Study or Hobbies:

Employed From ( yy/mm ):

Employed To ( yy/mm ):

Name and Address of Employer:

Ending Salary / Wage:

Position:

Reason for leaving:

Employed From ( yy/mm ):

Employed To ( yy/mm ):

Name and Address of Employer:

Ending Salary / Wage:

Position:

Reason for leaving:

Employed From ( yy/mm ):

Employed To ( yy/mm ):

Name and Address of Employer:

Ending Salary / Wage:

Position:

Reason for leaving:

Reference Name:

Address & phone Number:

Type of Business:

Years Known:

Reference Name:

Address & phone Number:

Type of Business:

Years Known:

Reference Name:

Address & phone Number:

Type of Business:

Years Known:

AUTHORIZATION

READ THIS CAREFULLY

By typing your name into the space below, you are agreeing to be bound by the following statements.

“I certify that the information I have provided in this application is true and complete to the best of my knowledge and I understand that one or more falsified statements within this application is grounds for dismissal.

I authorize the investigation of all statements contained herein. I further authorize the references and employers listed within to give you any and all information concerning my previous employment and hereby waive any liability for any damage that may result from use of this 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, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

I also agree to submit to drug and/or alcohol testing prior to employment and on a random basis if so requested by an authorized company representative. I understand that should the results of these tests be verified by a MRO as positive, I will not be hired on as an employee of this firm or I will be dismissed if employed by Stom Painters, Inc

This waiver does not permit the release of disability-related or medically-related information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”

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