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Employee Application

Please complete this form fully and accurately. TLC Diversified is an Equal Opportunity Employer and a Drug Free Workplace.

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1Applicant Info

2Position Info

3Education

4References

5Experience

6Equal Employment Info

Applicant Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Resume

Please upload your resume above.

Position Applied For *

Description *

Date available to start working: *

Desired Salary / Hourly Wage *

How did you hear about us? *

Other (please specify): *

Please indicate their name: *

First

Last

Are you a citizen of the United States? *

Have you ever been convicted of a felony? *

Are you currently employed? *

Do you have any obligations that would keep you from work-related travel? *

If yes, please explain why: *

Have you ever worked for this company in the past? *

Please tell us what your reason for leaving and who your supervisor was: *

Education

High School

Address: City & State

Did you graduate?

College Name

Address: City & State

Did you graduate?

Degree

Reference #1

Please list two professional references.

Name *

First

Last

Relationship *

Phone Number *

Company *

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Reference #2

Name *

First

Last

Relationship *

Phone Number *

Company *

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Employment

Job Title *

Company *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Responsibilities *

Starting Salary/Hourly Wage *

Ending Salary/Hourly Wage *

Date Started *

Date Ended *

Reason for leaving: *

Supervisor *

May we contact your previous supervisor for a reference? *

Equal Employment Opportunity Information

This information is being requested in accordance with federal regulations. The information is voluntary and will not be used when considering you for employment with our company.

Ethnicity

African American / Black
American Indian / Alaskan
HI-Pacific Islander / Asian
Hispanic / Latino
Two or more races

Gender

Male
Female

Military Service

Pre-Vietnam Era
Vietnam Era
Post-Vietnam Era
Disabled Veteran

Disclaimer & Signature

TLC Diversified complies with the Americans with Disabilities Act (ADA) of 1990. During the interview process, you may be asked questions concerning your ability to perform job-related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical history questionnaire and/or undergo a medical examination. If required, all entering employees in the same job category will be subject to the same medical questionnaire and/or examination. All information will be kept confidential and in separate files. I certify that the answers given herein are true and complete to the best of my knowledge. I authorize the investigation of all matter containing in this application and hereby give the employer permission to contact, but not limited to, schools, previous employers, references listed, workers’ compensation, law enforcement agencies, departments of motor vehicles, and others as necessary and hereby release the employer for any liability as a result of such contact. I understand that misrepresentations and/or omissions of facts called for in this application will be cause for dismissal at any time without any previous notice. * *

I agree

I understand and agree that all policies, procedures, whether written, published or orally communicated by the employer may be modified, amended, and/or deleted by the employer with or without notice to me. The employer’s policies and procedures are not intended to be a contract of employment nor do they give me a right of continued employment. If hired my employment may be terminated at my option or at the option of my employer with or without prior notice to either party. * *

I agree

I understand that if hired, I will be placed on a 90 day orientation period. I further understand that if I am terminated for unsatisfactory work performance or attendance events within this period, it will be considered misconduct and the employer may seek to deny any unemployment benefits I might attempt to obtain as a result of my termination. * *

I agree

TLC Diversified is a DRUG FREE WORKPLACE (DFW). If employment is offered it will be contingent upon the successful completion of a drug test. A copy of the DFW policy will be furnished to me once employment is offered. A confirmed negative drug test will result in that offer of employment continuing. A confirmed positive drug test will result in that offer of employment being withdrawn. It is a condition of continued employment that you must agree to future drug tests as per company policy and that any confirmed positive test result will be grounds for immediate termination. * *

I agree

I understand that this application remains current for 90 days. At the conclusion of that time, if I have not heard from TLC Diversified and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. * *

I agree

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I also understand that my employment at TLC Diversified is at-will and may be terminated by either myself or TLC Diversified at any time for any reason or no reason at all, with or without cause or notice. * *

I agree

Today's Date: *

Applicant Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Resume

Please upload your resume above.

Position Applied For *

Description *

Date available to start working: *

Desired Salary / Hourly Wage *

How did you hear about us? *

Other (please specify): *

Please indicate their name: *

First

Last

Are you a citizen of the United States? *

Have you ever been convicted of a felony? *

Are you currently employed? *

Do you have any obligations that would keep you from work-related travel? *

If yes, please explain why: *

Have you ever worked for this company in the past? *

Please tell us what your reason for leaving and who your supervisor was: *

Education

High School

Address: City & State

Did you graduate?

College Name

Address: City & State

Did you graduate?

Degree

Reference #1

Please list two professional references.

Name *

First

Last

Relationship *

Phone Number *

Company *

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Reference #2

Name *

First

Last

Relationship *

Phone Number *

Company *

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Employment

Job Title *

Company *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Responsibilities *

Starting Salary/Hourly Wage *

Ending Salary/Hourly Wage *

Date Started *

Date Ended *

Reason for leaving: *

Supervisor *

May we contact your previous supervisor for a reference? *

Equal Employment Opportunity Information

This information is being requested in accordance with federal regulations. The information is voluntary and will not be used when considering you for employment with our company.

Ethnicity

African American / Black
American Indian / Alaskan
HI-Pacific Islander / Asian
Hispanic / Latino
Two or more races

Gender

Male
Female

Military Service

Pre-Vietnam Era
Vietnam Era
Post-Vietnam Era
Disabled Veteran

Disclaimer & Signature

I agree

I agree

I agree

I agree

I agree

I agree

Today's Date: *