PRE-EMPLOYMENT APPLICATION

Gorjanc Comfort Services, Inc. is an equal opportunity employer and adheres to the principles and practices outlined in the Civil Rights Act of 1964, which prohibits discrimination in employment on the basis of race, sex, religion or national origin and Public Law 90-202 which prohibits discrimination based on age

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all question have been answered. This questionnaire is a pre-employment application only.

PERSONAL INFORMATION
Last Name, First Name, Middle Initial
Date
Home Phone
Address
Address 2
City
State/Province
Country
Zip/Postal Code
E-mail Address
Social Security No.
Are you 18 years old?
yes no
Are you a citizen of the United States, or do you have the legal right to be employed in the Uited States?
yes no
Have you ever been convicted of any crime (excluding minor traffic violations) including DWI?
yes no
If yes, state the offense, location, date and disposition
Who should be contacted in case of an emergency?
Last Name, First Name, Middle Initial
Home Phone
Address
City
State/Province
Country
Zip/Postal Code
Drivers License Info:
State
License No.
Type

EMPLOYMENT DESIRED
What type of employment are you seeking?
Full Time
Part Time
Temporary or Summer Employment
Position applied for
Salary Desired
Have you ever applied with us before?
yes no
Date available to start:
Have you ever worked here before?
yes no
If you ever applied or worked for us, state when and where you applied and/or worked.
How did you learn of our company and/or position?
Are you now or do you expect to be involved in any other business or employment?
yes no
Are there any days or hours you would be unable or unwilling to work?

MILITARY SERVICE
Have you ever served in the military?
yes no
Service Branch
What was your occupational speciality (MOS)?
What special training did you receive that may help you if employed by us?

PERSONAL / HEALTH
Can you lift a minimum of 70 lbs?
yes no
Can you perform all specfic tasks associated with the position you are applying forwithout special apparatus or with minimal changes or alterations to the company?
yes no
Have you used any illegal drug, including marijuana, in the last twelve months?
yes no
Have you ever had a conviction for; driving while intoxicated, or under the influence of drugs or alcohol?
yes no
Are you willing to take a physical exam and a drug screen at our expense?
yes no
How many days leave did you take last year?
How many Fridays & Mondays did you take as leave last year?

EDUCATION
Did you graduate from High School?
yes no
Courses Studied:
College?
yes no
Courses Studied:
Trade School?
yes no
Courses Studied:
Please List Your Strengths and Weaknesses.
Are you planning to pursue further studies?
yes no
If so, when and what courses:
List any scholastic honors, offices held and activities involved in during high school or college:
List and describe any other School or Specialized Training:

WORK HISTORY
List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give the firm name and supply business references. PLEASE GIVE MONTH AND YEAR.
Name of Employer
Address
City
State
Zip
Telephone
Title
Duties
Name and Title of Last Supervisor
Date Employed
From: monthYear
To: monthYear
Starting Pay
Ending Pay
Reason for Leaving
Name of Employer
Address
City
State
Zip
Telephone
Title
Duties
Name and Title of Last Supervisor
Date Employed
From: monthYear
To: monthYear
Starting Pay
Ending Pay
Reason for Leaving
Name of Employer
Address
City
State
Zip
Telephone
Title
Duties
Name and Title of Last Supervisor
Date Employed
From: monthYear
To: monthYear
Starting Pay
Ending Pay
Reason for Leaving
Have you ever worked under another name?
yes no
please give that name:
Are you presently employed?
yes no
If yes, may we contact your present employer?
yes no

SPECIAL SKILLS
Do you type?
yes no
Words Per Minute
Do you take Shorthand?
yes no
Words Per Minute
Have you had any computer or word processing experience or training?
yes no
If yes, please describe the extent:
What languages do you speak and or write fluently?
Use this space to describe why you are interested in working for us list the skills and abilities which you feel particularly qualify you for a position with us. Please attach a resume if you have one available.

REFERENCES
Name of
Address
City
State
Zip
Telephone
Occupation
Name of
Address
City
State
Zip
Telephone
Occupation
Name of
Address
City
State
Zip
Telephone
Occupation

AFFIDAVIT
I certify that the answers given by me to the foregoing questions and statements are true and correct without any intentional omissions of consequence of any kind whatsoever. I understand that any misleading or incorrect statements may render this application void and, if employed, would be cause for my termination. I further agree that you shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this questionnaire. I also authorize the companies, schools or persons named above to give any information regarding my employment, character and qualifications and hereby release said companies, schools or persons from all liability for any damage for issuing this information. I certify that all statements and answers to questions about my abilities are true and were made without reservations. Further I agree to expressly waive all provisions of law prohibiting any physician, person, hospital or other institution from disclosing to us any information regarding treatment rendered now and in the future. I further understand that the taking of a drug test and physical are a condition of employment and refusal to take such tests when requested will subject me to termination. I also understand that no person is authorized to enter into any written or verbal employment contract on behalf of us without the express written consent of the President. I understand my employment is at will. I further understand that I will be given an "employee handbook" outlining our rules and regulations.

By submitting this form, I hereby acknowledge that I have read, understand, and agree to the Affidavit and the terms listed above.