Application Form

Personal Information



Have you ever used another name?

Yes No

Is any additional information necessary to enable a check on your work and education record, such as a name change, nickname or use of an assumed name? If yes, please explain:

Yes No
Yes No

Have you ever been discharged from any position?

Yes No

If yes, please provide the date & reason for each discharge

Please provide the names of any relatives already employed by our organization

How were you referred to the Company?

Have you ever:

– been convicted in regard to any crime or offense(i.e. misdemeanor, felony, traffic violation, etc.) for which the record has not been sealed or expunged?

Yes No

– pled guilty in regard to any crime or offense(i.e. misdemeanor, felony, traffic violation, etc.) for which the record has not been sealed or expunged?

Yes No

– received a suspended imposition of sentence in regard to any crime or offense(i.e. misdemeanor, felony, traffic violation, etc.) for which the record has not been sealed or expunged?

Yes No

If yes, please briefly describe the nature of the offense(s), the date and place of conviction and the legal disposition of hte case. This company will not deny employment to any applicant solely because hte person has been convicted of an offense. The company however, may consider the nature, date and circumstances of hte offenses as well as whether the offense is relevant to the duties of the position applied for.

Are your currently out on bail; the subject of a current warrant for arrest or released on your own recognizance pending trial? Answering yes will not necessarily be disqualifying.

Yes No

Salary/Hourly Rate Requirements

Job Related Skills

Have the requirements and skills of the job been explained to you or have you been given a copy of the job description for the position for which you have applied?

Yes No

Do you understand these requirements and skills of the job position?

Yes No

Can you perform the essential functions of the job with or without reasonable accomodation?

Yes No

If your application receives favorable consideration, when will you be available to begin work?

Yes No
Yes No

Yes No
Yes No

Yes No
Yes No

Yes No
Yes No

Educational History




Have you served in the US Military?

Yes No

If yes, did your military service and training provide you with skills you could put to use in this job?

Yes No

Employment Record


  1. Yes No

  2. Yes No


  3. Yes No

  4. Yes No

References

List those person who are familiar with your work skills and ability. Do not include relatives






Please read the following carefully before you sign and submit this employment application

Benjamin Franklin Plumbing is an Equal Opportunity Employer which makes employment decisions without regard to race, color, sex, religion, national origin, age , disability or marital status. This Company also complies with the Americans with Disabilities Act of 1990. During the interview process, you may be asked questions concerning your ability to perform job-related functions. This Company reasonably accommodates qualified individuals with disabilities and bona fide religious beliefs.

This application form is intended for us in evaluating your qualifications for employment. This is not an employment contract. Please note that any false or misleading statements made during hte interview process or on the application or other company forms are grounds for immediately terminating: (1) the interviewing process (2) the conditional offer of employment or (3) employment if discovered after hiring. All qulaified applicants will receive consideration without regard to any status or condition protected by law. A conviction will not necessarily bar an applicant from employment. If you appear to be qualified for the position applied for based upon the information on your application form and/or job interiew, the company may make a conditional offer contingent upon submitting to the company's substance abuse testing and the verification of your answers to any requested information through reference and background checks. If you receive a conditional job offer, your conditional job offer may be rescinded if the company's substance abuse testing indicates that you are not in compliance with the company's substance abuse policy or if reference and background check information reveals information that leads the company to believe the employment offer should be withdrawn.

This application for employment has been accepted for consideration regarding the active position vacancy you indicated on the front page. Benjamin Franklin Plumbing does not accept unsolicited resumes or applications. If you wish to be considered for employment for future active position vacancies, you will be required to submit a new employment application at that time.

In the event that you are hired for a position with the company, you acknowledge (a) that your employment is terminable at will, either by yourself or the company at any time and for any lawful reason and (b) that no contract of employment other than "at will" has been expressed or implied, and that no circumstances arising out of your employment will alter your "at will" employment relationship unless expressed in writing.

Authorization to Obtain a Consumer Credit Report and Relase of Information for Employment Purposes

Pursuant to the federal Fair Credit Reporting Act, I hereby authorize Benjamin Franklin Plumbing and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: verification of Social Security number; current and previous residences; employment history, including all personnel files; education; references; credit history and reports; criminal history, including records from any criminal justice agency in any or all federal, state or county juridistictions; birth records; motor vehicle records, including traffic citations and registration, and any other public records.

I authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation or public agency may have. I understand that I must provide my date of birth to adequately complete said screening and acknowledge that my date of birth will not affect any hiring decisions. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish Benjamin Franklin Plumbing or its designated agents with any and all information in their possession regarding me in connection with an application of employment. I am authorizing that a photocopy of this authorization be accepted with the same authority as the original.

I hereby release Benjamin Franklin Plumbing and its agents, officials, representatives or assigned agencies, including officers, employees or related personnel, both individually and collectively, from any and all liability for damages fo whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release. You may contact me as indicated. I understand that a copy of this authorization may be given at any time, provided I do so in writing.

I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer's right will be provided to me.

Certification by Applicant

I certify that I have read and understand the instructions and information on this application form and all other forms that have been given to me by the company.

I authorize the company and or its agents to verify any information that I have provided adn to investigate my background and all statements contained in this employment application as may be necessary to arrive at an employment decision. I authorize all current and former employers, persons, education instutions, companies and/or law enforcement authorities to release any information concerning my background. I hereby rlease and hold harmless all such current and former employers, persons, schools, companies, law enforcment authories and Benjamin Frnaklin Plumbing from any liabilitiy or damages whasoever for attempting to., obtaining, providing, or using any such information.

I understand that employment is not for any guranteed term and may be terminated byt the Company or employee at any time for any reason. I further understand that this "at will" employment relationship may not be changed by any written document, verbal statement, or conduct unless such change is specifically acknowledged in writing by an authorized executive of the organization in a written document titled "Employment Contract," and whcih specifically state the employee is not an "at will" employee.

In the event of employment:

I understand that false, misleading or omitted information given in my employment application, interview(s) or any other doucments or statement, may result in discharge.

I also understand that I am required to abide by all rules and regulations of the meployer

I understand that Benjamin Franklin Plumbing is committed to providing a drug-free workplace and that a positive durg test result may be grounds for termination of employment

I understand that I will be subject to a ninety (90) day introductory period and that during this timeframe I may be released at any time for any reason other than for any status or conditon protected by law.

I certify that all information (in writing or otherwise) given by me to the company is complete, accurate and true ot the best of my knowledge and belief.