Employment Application | BHI Services LLC

1

Position Information

Position Applied For * Required.

Date Available *

Required.

Department

Desired Pay

Employment Type

Full-TimePart-TimeTemporarySeasonal

Shift Preference

DayEveningNightWeekendsFlexible

How Did You Hear This Position?

IndeedLinkedInEmployee ReferralCompany WebsiteWalk-InOther

If Referral — Referred By

2

Personal Information

First Name *Required.

Middle Name

Last Name *Required.

Preferred Name

Date of Birth *

Required.

Social Security Number *Required.

Street Address *Required.

City

State

Zip

How Long At Address?

Previous Address (if less than 2 years at current)

Phone (Primary) *Required.

Phone (Alternate)

Email Address *Enter a valid email.

Authorized To Work In The U.S.? *

Required.

Require Visa Sponsorship?

Are You 18 Or Older? *

Required.

3

Education

List most recent education first.

Education 1 — Most Recent

School Name

City & State

Type

High SchoolVocational/TradeAssociate'sBachelor'sMaster'sDoctorateOther

From (Year)

To (Year)

Graduate?

Degree / Diploma / Certificate

Education 2

School Name

City & State

Type

High SchoolVocational/TradeAssociate'sBachelor'sMaster'sDoctorateOther

From (Year)

To (Year)

Graduate?

Degree / Diploma / Certificate

Additional Training, Skills, Or Licenses Relevant To The Position

4

Employment History

List all employment for the past 10 years, beginning with your most recent employer.

Employer 1 — Most Recent

Employer Name *Required.

Job Title *Required.

Supervisor Name

Supervisor Phone

Start Date

End Date

Type

Starting Pay

Ending Pay

Address (Street, City, State, Zip)

Responsibilities

Reason For Leaving

May We Contact?

Employer 2

Employer Name

Job Title

Supervisor Name

Supervisor Phone

Start Date

End Date

Type

Starting Pay

Ending Pay

Address (Street, City, State, Zip)

Responsibilities

Reason For Leaving

May We Contact?

Have You Ever Been Terminated Or Asked To Resign? *

Required.

If Yes, Please Explain

5

Professional References

List three professional references. Do not list family members or former supervisors already listed above.

Reference 1

Name *Required.

Relationship / Title

Company / Organization

Phone *Required.

Email

Years Known

Reference 2

Name *Required.

Relationship / Title

Company / Organization

Phone *Required.

Email

Years Known

Reference 3

Name *Required.

Relationship / Title

Company / Organization

Phone *Required.

Email

Years Known

6

Background Information

A criminal record is not an automatic disqualification. Answers will be considered in relation to the job applied for.

Convicted Of A Felony? *

Required.

Convicted Of A Misdemeanor?

Pending Charges?

If Yes To Any Above — Date, Offense, Disposition

Valid Driver's License? *

Required.

License Number

State

Expiration

Moving Violations In Past 3 Years?

If Yes, List Violations

Able To Perform Essential Functions With Or Without Accommodation? *

Required.

If No, Describe Accommodations Needed

7

Applicant Authorization & Signature

I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that falsification, misrepresentation, or omission of any information is grounds for rejection of this application or, if hired, immediate dismissal. I authorize BHI Services LLC to verify all information contained herein, including contacting former employers, educational institutions, and references. I understand that employment is contingent upon the successful completion of a background check and any other pre-employment requirements. I understand that this application does not constitute a contract of employment.

I have read and agree to the certification above. Typing my name below serves as my electronic signature. *

Applicant Signature *Required.

Date *

Printed Name *Required.

Position Information

Personal Information

Education

Employment History

Professional References

Background Information

Applicant Authorization & Signature

Application Received!