Pekar's Body Shop, Inc.
Application For Job Assignment
Date:_________________________ Position you are applying for:______________________
Personal Information
_______________________________________________________SS#__________________
Name: (Last) (First) (Middle)
Current Address:______________________________________________________________
Permanent Address (if different):________________________________________________
Prior Address:________________________________________________________________
Telephone number(s) where you can be reached:
Day_________________________Evenings/Weekends_______________________________
Are you 18 years of age or older____yes ___no
Are you eligible to work in the United States? ____yes ____no
Whom do we notify in case of an emergency?_____________________________________
Have you ever been convicted of a felony? _____yes _____no
If you answered yes to the above question please fill out the next 3 lines.
City/State of the conviction________________________Charge______________________
Please explain:_______________________________________________________________
___________________________________________________________________________
*Conviction of a felony will not necessarily bar you from employment. Neglecting to answer
honestly gives Pekars the right to fire you without notice.
Education
Please circle the highest grade completed in school:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Name and address of last school attended:_________________________________________
____________________________________________________________________________
College, Vocational or Business schools attended:___________________________________
____________________________________________________________________________
Drug Testing
Before an offer of employment or at any time during employment, you may be asked to take a drug test.
Medical Exam And Mobility Evaluation
Applicant information statement: (to be read by applicant).

Employment at this business requires all employees to be fit to perform any physical and/or mental activities related to their jobs, as well as to appear regularly and on time for work as assigned.

After an offer of employment is made to you and before you report to work, you are required to submit to a medical review. Depending on company policy and the needs of the job, you may be required to be examined by a medical professional chosen by the company.
Employment Records
In order for your application to be considered, every question must be answered. Correct phone numbers are very important.
Are you currently employed? ____yes ____no
We routinely contact an applicant's current employer for reference checks. Would this pose a particular difficulty for you? ____yes ____no
If yes, please explain___________________________________________________________
____________________________________________________________________________
Current Or Most Recent Employer:
Name____________________________________________Phone______________________
Address_____________________________________________________________________
Position/Duties_______________________________________________________________
Worked for this employer From ______/______ to ______/_______
Supervisor___________________________________________________________________
Reason for leaving_____________________________________________________________
Next Previous Employer:
Name____________________________________________Phone______________________
Address_____________________________________________________________________
Position/Duties_______________________________________________________________
Worked for this employer From ______/______ to ______/_______
Supervisor___________________________________________________________________
Reason for leaving_____________________________________________________________
Next Previous Employer:
Name____________________________________________Phone______________________
Address_____________________________________________________________________
Position/Duties_______________________________________________________________
Worked for this employer From ______/______ to ______/_______
Supervisor___________________________________________________________________
Reason for leaving_____________________________________________________________
References
Name
Phone/Address
Position
Years Known
_____________________ ___________________________ ______________ ____________
_____________________ ___________________________ ______________ ____________
_____________________ ___________________________ ______________ ____________
Use this space to give us other information about your personal skills or qualities, work style, interpersonal abilities or communication skills which would further qualify you for this job.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Applicant's Certification And Agreement:

I certify that all information given on this application is true, correct, and complete. I also certify that I have accounted correctly for my work experience, education and training.

I understand that misrepresentation or omission of facts will be cause for cancellation of my consideration for employment, or dismissal if employed. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information contained in this application including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

I further understand and agree t hat employment by this company will be "at will." That is, either I or the company may end the employment relationship at any time for any reason or for no reason. Also, I understand that no representative of the company has the authority to enter into any agreement with me for employment for any specific period of time or make amy agreement with me contrary to the foregoing.

I further certify that I have no objections to the following conditions concerning my employment:
1. Submitting to a medical review and an examination by a medical professional chosen by the company after a conditional job offer has been made and before reporting for work, as determined by the needs of the job and company policy.
2. Taking a physical agility test if required.
3. Submitting to a drug examination when requested by the company as stated in the company Drug Testing Policy.
4. Demonstrating the skill and ability to perform the essential functions of the assigned job.
5. Available for overtime when scheduled.
6. Returning all company issued items at the time of termination
7. Abiding by the rules and regulations of the company.
8. Available to work any shift, any department, or any job when assigned by the company at the prevailing rate at that time.
9. Submitting to a security search when requested by the company.
I have read and understand the above.
Date_____________________________
Print employee's name:__________________________________________________
Signature of employee:__________________________________________________
Social Security Number:_________________________________________________