Give the names of three persons not related to you, whom you have known at least one year.
Address and Phone Number
I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED; FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU.
I UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT AT QUALITY PLUS IS AT WILL AND MAY BE TERMINATED BY MYSELF OR BY QUALITY PLUS AT ANY TIME WITH OR WITHOUT CAUSE OR NOTICE.
APPROVED: 1.) 2.) 3.) EMPLOYMENT MANAGER DEPARTMENT HEAD GENERAL MANAGER
EMPLOYEE REFERENCE REQUEST
I, ____________________________, hereby authorize ____________________________________________
Applicant Print names of ALL FORMER EMPLOYERS listed on previous page
to release any and all references and records related to my past employment and work history to Quality Plus Automotive Parts, Inc. I release and discharge both my former and prospective employers from any and all claims or actions related to this Employee Reference Request and any related exchange of records or other communications concerning my past employment.
Printed Name (Last, First, MI):
Social Security Number:
APPLICANT: DO NOT WRITE BELOW THIS LINE
The following is to be filled out by former employers.
Please answer the following questions as thoroughly as possible regarding the above named individual and their employment with your company. Your assistance is greatly appreciated.
Por favor conteste las siguientes preguntas con respecto al individuo arriba nombrado y su empleo con su compañía. Su ayuda es agradecida.
Start Date / Fecha de Contratación:
End Date / Fecha de Ultimo Día de Trabajo:
Final Position or Title / Ultimo Puesto o Titulo :
Final Salary / Ultimo Salario
Time in Final Pay Grade /
Tiempo con ese salario?
Your Relationship to Employee / Su relación hacia el empleado (gerente, supervisor, etc.)
Position Summary / Breve descripción del puesto que ocupo el individuo:
Essential Job Functions / Funciones esenciales del trabajo del individuo:
Reason For Leaving / Razón por cual el individuo dejo el trabajo :
Is this Individual Eligible for Rehire? / ¿Es elegible el individuo para re-contratación?
( ) Yes / Si ( ) No
If no, please explain / Si su respuesta fue “No”, podría explicar las razones por su respuesta:
What Is Your Opinion of this Individual’s Ability to Add Value to Our Company?
Cual es su opinión sobre la habilidad que tiene esta persona para agregar valor a nuestra empresa?
Signature / Firma
Date / Fecha:
Drug-Free Workplace Agreement/Consent Form Substance Regulations:
The manufacture, possession, use, purchase or distribution of illegal drugs (meaning those drugs for which there is no generally accepted medical use, e.g. marijuana, cocaine, methamphetamine, etc.) or paraphernalia associated with illegal drugs by an employee on Company or client property, in a Company or client vehicle, or during work hours is strictly prohibited. Substantiated evidence or noncompliance will result in employment termination.
The use of alcohol by an employee on Company or client property, in a Company or client vehicle is strictly prohibited. Substantiated evidence of noncompliance will result in employment termination.
Reporting to work or working while intoxicated by alcohol or under the influence of any controlled substance is specifically prohibited and may result in termination.
Quality Plus Automotive Parts, Inc. reserves the right to require testing of employees involved in work-related accidents, and/or when the Company has “reasonable cause” to believe that an employee is under the influence of controlled substances and/or alcohol.
As a condition of employment with Quality Plus Automotive Parts, Inc., candidates for placement will be required to take and pass a drug-screening test. This will normally be post offer/pre-employment.
Employees who operate vehicles as part of their Quality Plus Automotive Parts, Inc. responsibilities must notify their supervisor or appropriate Company manager when they are taking prescription or non-prescription medication which contains a WARNING LABEL stating that the use of that drug may impair their ability to safely operate machinery or vehicles.
I have read the above statements. I understand and agree to submit to any post-offer/pre-employment and post-hire drug and alcohol testing and authorize the release of all results to Quality Plus Automotive Parts, Inc. and I hereby release Quality Plus Automotive Parts, Inc., any examining physicians and any and all testing individuals and facilities, their agents and employees from any and all liability that allegedly may result. I UNDERSTAND THAT IF I TEST POSITIVE FOR THE PRESENCE OF ILLEGAL DRUGS, SUBSTAMCES OR ALCOHOL, ANY OFFER OF EMPLOYEMENT WILL BE TERMINATED. I FURTHER UNDERSTAND AND CONFIRM THAT NO PROMISES OR ASSURENCES HAVE BEEN MADE TO ME REGARDING EMPLOYEMENT OR THE RETENTION THEREOF IN THE EVENT THAT I AM EXAMINED AND/OR TESTED EVEN THOUGH I MAY PASS ALL ASPECTS THEREOF.