ImpactLex Employment Application

  • Applicant Information:

  • Employment Position

  • Format Should Look As Follows: 00/00/0000
  • Additional Information:

  • Employment History:

  • Format Should Look As Follows: Name of Employer: Name of Supervisor: Telephone Number: Business Type: Address: City, State, Zip: Date of Employment(EX. 05-14-06-14) Position and Duties: Reason For Leave:
  • List Up To Three References That We May Contact: Should Look as Follows: Name: Telephone: Address: City,State,Zip: Number of Years Known:
  • Education:

  • Please Read and Initial Each Paragraph, Then Sign and Date Application:

  • I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission, including any misstatements, of material fact on this application or on any document used to secure can be grounds for rejection of my application or, If I am employed by this company, terms for my immediate termination from the company.
  • I permit the company to examine my references, records of employment, records of education, and any other information I have provided to include: AOC check, CAN check, KNAR check, TB Test, and First AID/CPR certification. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelations.
  • Sign and Date:

    By typing your full name you comply with all fore mentioned terms and conditions. If full name including middle name is not included, all previous application work will be disregarded.
  • First/Middle/last
  • First/Middle/Last
  • 00/00/0000