Full Name *
Current Address *
Email Address *
Phone Number *
At this address since (date): *
Work interest preference *
State any hours or days you CANNOT work
Valid Driver's License? *
Use public transportation only? *
Own a dependable automobile? *
Date of birth: *
Social security number:
Wear glasses? *
Wear contact lenses? *
Military Service? (If "YES", complete below:)
Branch of service:
Type of discharge:
Date of service:
( Check all that apply)
Present Employer (If employed):
Street (Address 1)
City (Address 1)
Street (Address 2)
City (Address 2)
Street (Address 3)
City (Address 3)
1-Have you ever been discharged for Dishonesty?
2-Have you ever been discharged for Insobriety?
Explain all “YES” Responses
3-Have you ever been arrested or convicted of a crime?
Have you ever used or tried marijuana, cocaine, or any other illegal drug?
How many times?
Last time use or tried:
Explain “YES” Responses
Answers to the following questions provide a guide for determining the type of assignments you are best suited for. Check either “Yes” or “ No” for each question. Answer every question.
1-Can you stand for an eight hour period? *
2-Can you run 100 yards without stopping? *
3-Can you distinguish colors? *
4-Can you drive a Vehicle? *
5-Can you monitor CCTV? *
6-Can you hear normal conversation on a standard telephone? *
7-Can you walk 50 minutes out of each Hour for an 8-hour period? *
8-Can you sit for extended period of time? *
9-Can you smell smoke, chemical and gas odors? *
10-Can you bend and squat? *
11-Can you stay calm in Emergencies? *
12-Can you hear Telephone rings? *
13-Can you dial a telephone? *
14-Can you ride a bicycle? *
15-Can you read signs for directions Such as left, right, up and down? *
16-Can you work regular schedule Without incurring unexpected absences? *
17-Can you respond to emergencies? *
18-Can you maintain alertness for Extended periods to respond to an emergency? *
Understand that any false or misleading information provided by me on this application shall be grounds for immediate dismissal any time during my employment with Unified. It is understood that my employment is subject to my satisfactorily meeting the requirements of a security background investigation, to which I hereby consent, and subject to undergoing a medical examination the results of which how that I can perform the essential functions of the job, with or without reasonable accommodation, without posing a direct threat to the health or safety of myself or others.
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