Form

EMPLOYMENT HISTORY
Please list your employment history beginning with your most recent position. This MUST be completed whether or not you attach a resume. Employment dates must be consecutive and all times accounted for. Include Military Service if applicable.
Most Recent Employer
Address
From (mo./yr.)
To (mo./yr.)
Starting Position
Last Position
Name of Supervisor
Title
Phone No./Ext.
May we contact this employer?

Yes No
Description of Duties
Reason for leaving
Previous Employer
Address
From (mo./yr.)
To (mo./yr.)
Starting Position
Last Position
Starting Base Salary
Name of Supervisor
Title
Phone No./Ext.
May we contact this employer?

Yes No
Description of Duties
Reason for leaving
Previous Employer
Address
From (mo./yr.)
To (mo./yr.)
Starting Position
Last Postition
Name of Supervisor
Title
Phone No./Ext.
May we contact this employer?

Yes No
Description of Duties
Reason for leaving
Previous Employer
Address
From (mo./yr.)
To (mo./yr.)
Starting Position
Last Position
Name of Supervisor
Title
Phone No./Ext.
May we contact this employer?

Yes No
Description of Duties
Reason for leaving

INDICATE SKILLS IN THE FOLLOWING AREAS IF APPLICABLE
Type
WPM
What office equipment can you operate proficiently?
Can you perform the essential functions of the position applied for, with or without reasonable accommodations?

Yes No
If no, please explain the functions that cannot be performed.
In order of proficiency, list your technical skills:
PROFESSIONAL REFERENCES
Please give the names of three people in your field (past managers or supervisors) who know you and can provide information regarding your job-related capabilities.
Name
Title
Company
Phone Number

- Area Code Phone Number
Name
Title
Company
Phone Number

- Area Code Phone Number
Name
Title
Company
Phone Number

- Area Code Phone Number
PERSONAL REFERENCES
Please give the names of three people in your field (past managers or supervisors) who know you and can provide information regarding your job-related capabilities.
Name
Title
Company
Phone Number

- Area Code Phone Number
Name
Title
Company
Phone Number

- Area Code Phone Number
Name
Title
Company
Phone Number

- Area Code Phone Number

-IMPORTANT-

PLEASE READ CAREFULLY
AUTHORIZATION AND RELEASE
CERTIFICATION

I certify that my answers in this application and in my personal interview are true and correct. I agree that any omissions, misrepresentations or falsifications of information may disqualify me from employment and, if hired, may be grounds for termination of employment.

I understand this application is not an employment contract nor can it be used to create a contract. Employment by PITCO FOODS has no specific term, regardless of length of service, and may be terminated at the will by either party. I acknowledge that PITCO FOODS has not made any promises or representations that differ from those contained in this paragraph. Promises or guarantees of employment on any other basis are not binding for PITCO FOODS unless they are written and signed by the Owner/President of the Corporation.

I hereby authorize PITCO FOODS to conduct background investigations and check references in association with this application for employment. Further, I authorize any individual, company, business entity, institution, or government agency having relevant information to furnish PITCO FOODS with that information.

I hereby release and agree to hold harmless any individual, company, business entity, institution, or govenment agency from all liability with regard to furnishing that information to PITCO FOODS. Further, I hereby agree to release and hold PITCO FOODS harmless from all liability with respect to the receipt of such information.

I have read and understand all the above limitations on and conditions of my employment and authorize the investigation, etc. referred above.
E-Signature *
Date

- Month - Day Year
Thank you for your interest.
PITCO FOODS, Inc. is an equal opportunity/affirmative action employer.

DISCLOSURE AND AUTHORIZATION TO OBTAIN INVESTIGATIVE CONSUMER REPORT
As part of the PITCO FOODS, Inc. employment screening and selection process, a background and reference check is required for all employees. The objective of this process is to verify the accuracy of information provided in the application process, check references and identify other factors that might be relevant to PITCO FOODS’ employment requirements. You have the right, upon written request made within a reasonable period of time (not to exceed 30 days) after receipt of this notice to receive a written disclosure of the nature and scope of nay investigation conducted by a Consumer Reporting Agency. If an Investigative Consumer Report (ICR) is obtained and an adverse decision is made affecting your employment, PITCO FOODS will provide to you, before making the adverse decision, a copy of the ICR and a copy of your rights under the Fair Credit Reporting Act. PITCO FOODS reserves the right to run an ICR and/or drug screen as PITCO FOODS deems necessary at any time during your employment with PITCO FOODS. You have a right to obtain a copy of your ICR by checking the box provided below.

By signing this form, I authorize PITCO FOODS to obtain an Investigative Consumer Report, and/or drug screen as necessary at any time during my employment with PITCO FOODS. I understand that these reports may include and is not limited to information as to my character, general reputation, personal characteristics, mode of living, work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. Further, I understand and authorize PITCO FOODS to request information from various federal, state, and other agencies, including public and private sources which maintain records concerning my past activities relating to my driving record, credit history, criminal record, civil matters, previous employment (including salary), educational records and professional licensing if any. I further authorize that PITCO FOODS and its agents may disclose any information submitted for employment including, but not limited to information from my employment application, testing results, results of reference checks, credit, and criminal or driving record reports to client-companies as necessary.
APPLICANT INFORMATION
First Name
Middle Name
Last Name
Maiden or other names used
Social Security Number
Issuing State
Year Issued
Date of Birth*
Driver's License Number
State
PLEASE PROVIDE 7 YEARS OF ADDRESS HISTORY
Current Street Address
City
State
Zip
Length: yr./mos.
Previous Street Address
City
State
Zip
Length: yr./mos.
Previous Street Address
City
State
Zip
Length: yr./mos.
Previous Street Address
City
State
Zip
Length: yr./mos.
Current Phone Number

- Area Code Phone Number
E-Signature *
Date

- Month - Day Year
I wish to be furnished with a Copy of my Consumer Report

Yes No
*The Age Discrimination Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
Should be Empty:

-IMPORTANT-