Bestech Incorporated of Connecticut - Employment Application

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You may apply for Employment on-line using the below form. Please answer all questions. We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. AA/EEO

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Position Applied For:
Desired Salary:
Last Name:
First Name:
Middle Name:
Address:

City:
State:
Zip Code:
Social Security Number:
Date of Birth:
Phone:
Cellular:
E-mail:

Years of Experience Working with Asbestos:
Have you ever filed an application with us before?	Yes No
If yes, please specify the date:

Are you currently employed?	Yes No
If yes, may we contact your current employer?	Yes No

Are you a citizen of the United States?	Yes No
Do you have legal right to work in the United States?	Yes No
Proof of citizenship or immigration status will be required upon employment.

On what date would you be available for work:
Are you available to work: Full Time Part Time Shift Work Temporary

Do any of your friends or relatives work here?	Yes No
If yes, provide their names and relationship:

Voluntary Demographic Data
Gender:
Race:
Veteran:
Disability:

Previous Employment

Please provide the details of your previous employer:

Name of Employer:
Telephone Number:
Address:

City:
State:
Zip Code:
Supervisor's Name:
Supervisor's Title:

Date Employed From:	Date Employed To:
Starting Rate of Pay:	Final Rate of Pay:

Title:
Reason for leaving:
Describe the work performed:

Skills & Qualifications

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position you are applying for:

References
Please list names and telephone number of two professional references who are not related to you and are not a previous supervisor.
Name:
Title:
Phone:
E-mail:
Relationship:
Number of years known:

Name:
Title:
Phone:
E-mail:
Relationship:
Number of years known:

Disclaimer and Signature

Please read the following and sign below:

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly Authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local law. This company likewise does not tolerate harassment based on sex, race color, religion, national origin, citizenship, age, disability, or any other protected status.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

I agree that when I complete the "signature" fields below in this electronic document/form and submit it, I understand that it is the same as my handwritten signature for the purposes of validity, enforceability, and admissibility.

Signed:
Date: