Position applying for:
Hourly rate expected:
Will you accept part-time (less than 40 hours/week) or on-call work?
Do you have a valid Montana Driver License?
If hired can you show proof of authorization to work in the U.S.? (Verification will be required.)
Have you been employed here before?
If yes, give dates:
Please list the times in a typical week when you would not be available to work.
(All education listed will be confirmed with the school(s).)
Name & Location:
Course of Study:
Describe any other training (workshops/seminars) you have completed that will qualify you:
List any professional certifications or licenses you have earned:
Start with your present or last job and go back five (5) years, listing former employers. You may include military service assignments and volunteer activities.
Reason for Leaving:
Initial Pay Rate:
Final Pay Rate:
Most recent supervisors or instructors are required. Do not list friends or relatives.
Can you perform all the essential functions of the position for which you are applying with or without a reasonableaccommodation?
1. Have you ever been convicted for neglect or abuse, sexual abuse, or other acts of violence?
2. Are you currently being investigated for neglect or abuse of any kind?
3. Have you ever been terminated from any job for any reason other than a layoff?
Please provide dates and explanations if you answered "Yes" to any of the last three questions.
Have you ever been convicted of any criminal offense, either misdemeanor or felony?
If yes, please explain:
Do you have any tickets on your driving record?
If yes, please explain:
I give A.T. Klemens my permission to conduct a background investigation. I hereby authorize any law enforcement agency and/or child protection agency to release any records they have regarding me to A.T. Klemens. I understand that my potential employment is contingent upon these reports. A photocopy of this form is as valid as the original.
I authorize A.T. Klemens to obtain a copy of my motor vehicle record to evaluate my insurability or for other permissable uses related to my application. If I am hired for employment by A.T. Klemens, I hereby authorize A.T. Klemens to procure these records on a periodic basis or as deemed necessary to evaluate my continuing insurability.
The following information is needed for the background check and the motor vehicle check.
Date of birth:
Social Security Number:
Full name given at birth:
Driver License Number:
Driver License State:
I hereby authorize A.T. Klemens to inquire as to my record with any or all of my former employers with no liability arising therefrom. I hereby certify that all information above is true and complete to the best of my knowledge. I am aware that falsification or misrepresentation of required information is grounds for dismissal or disqualification from employment with A.T. Klemens
I understand that if I am employed by A.T. Klemens it may change wages, benefits, and conditions at any time and that there is no guarantee of permanent employment.
Please list any additional comments or special qualifications you would like to be considered: