Apply for a position


Personal Information


First Name


Last Name


Street Address




Zip Code


Phone Number


Referred by:


Employment Desired


Position Desired:


Date You Can Start:


Currently Employed?


Desired Salary:


Every Convicted of a Felony?


Type of Current
Drivers License:



(Please fill in all that applies)


High School


Year of Graduation:


College Attended
(if applicable)


Year of Graduation:


Trade, Business,or
Correspondence School
(if applicable)


Year of Graduation:


Please briefly indicate the level of experience or training/skills you've aquired pertaining to
your desired postion at PERCS:


Former Employers


Please list below your last two employers, beginning with the most recent one first. Indicate the period of time your were employed there, the name and address of employer, your position and salary while employed there, and your reason for leaving the company.






Military Service (if applicable)



Time Served


Rank at Discharge:


Type of Discharge:



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 authorized investigation of all statements
contained herein and the references and employers listed above to give you any and all information concerning my previous
employment and any pertinent information they may have, personal or otherwise, and release the company of all liability for
any damage that may result from utilization of such information. I also understand and agree that no representative fo the
company has any authority to ener into any agreement for employment for any specified period of time, or to make any
agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver
does not permit the release of use of disability-related or medical information in a manner prohibited by the Americans with
Disabilities Act (ADA) and other relevant federal and state laws.