Application For Employment
First Name:*  Middle Name:  Last Name:* 
Curr Address:*  City:*  State:*  Zip:*  County:*  Years Lived?* 
Prev Address:  City:  State:  Zip:  County:  Years Lived?: 
Home Phone:*  - - Cell Phone:  - - E-mail:* 
Do you have any relatives working for Brilex?*
Name: Relationship:
Are you legally authorized to work in the United States?*
(Proof of eligibility will be required before you can be employed)
Are you at least 18 years old?*
What date are you available for employment?*
Date:
What position are you applying for?*
Position:
Have you ever applied to/worked here before?* How did you become aware of the job opening?*
To
Last Applied:
Other:
Referred By:
Station:
Website:
Do you posess a valid driver's license?* Have you ever been convicted of a crime?
(Any felonies and/or misdemeanors)
*
License Number: Class:
Restrictions: State:
Explain:
Are you presently on layoff or leave of absence from any other company?* Do you have any agreements with another employer that might affect your employment here?*
Explain:
Explain:
Only answer the following question if you have been provided with a job description identifying the “essential functions” for the position you are applying for. Are you able to perform the essential functions of the job for which you are applying either with or without reasonable accommodation?
If you answered YES to the previous question and require reasonable accommodation, it is required that you have further discussion with Human Resources to discuss your reasonable accommodation request(s).
Employment Data
List past employment record as completely as possible starting with most current employer (including military service). Do not indicate “SEE RESUME”.
Employer Name /
Address /
Phone Number
Date Started /
Finished
Status /
Earnings /
Supervisor
Nature of Work /
Reason for leaving
Name:
Address:
Phone: - -

To
Present
Status:
Wage:
Sup. Name:
Nature of Work:
Reason for Leaving:
Name:
Address:
Phone: - -

To
Present
Status:
Wage:
Sup. Name:
Nature of Work:
Reason for Leaving:
Name:
Address:
Phone: - -

To
Present
Status:
Wage:
Sup. Name:
Nature of Work:
Reason for Leaving:
Name:
Address:
Phone: - -

To
Present
Status:
Wage:
Sup. Name:
Nature of Work:
Reason for Leaving:
Education & Training
High School Name / City / State
Name:*
City:*
State:*
Grade Completed:*
Did You Graduate?*
Did you obtain your GED?
College Name / City / State Graduated? Degree GPA Major(s)
Name:
City:
State:

Name:
City:
State:

Other job-related schooling, licenses, certs, etc. Institution Name Expiration Date
1.
Never
2.
Never
References
Provide three (3) work references that have direct knowledge of your work, experience and ability/skill.
Name* Address* Phone Number* Occupation* Relationship to You*
1. - -
2. - -
3. - -
Work Preferences
Answer only the questions for which you are applying
What type of employment do you want?*
Are you willing to travel?*
What percent of the time?
What is your minimum salary requirement?*
Salary Required:
As an applicant for employment, I understand the following:
  • This application will remain on active file for ninety (90) days. If I am hired within this period, this form will be transferred to my individual personnel file.
  • If I am not hired within ninety (90) days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a position after that time.
  • 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 misstatement) of material fact on this application can be grounds for rejection of application or if employed by this company, grounds for immediate termination of employment.
  • After an offer of employment has been extended, I will be required to submit to a drug/alcohol screening. If the results of the drug/alcohol screen are positive for substance abuse, this will be grounds for disqualifying me and/or terminating my offer of employment.
  • I understand that my employment is considered to be At-Will and is not guaranteed for any length of time. Either the Company or I can terminate the employment relationship at any time, with or without cause or with or without notice. No one except the President of Brilex Tech is authorized to enter into any employment agreement. To be enforceable, this agreement must be in writing, and signed by the President.
  • All information (including information on any accompanying resume) is subject to background check verification.
I authorize Brilex Tech to contact any present, (if specifically authorized above) or former employer(s), education institution, law enforcement agency, financial institution, or other persons having personal knowledge about me, to provide information requested by a third party background check organization or Brilex Tech in connection with my employment. Further, I hereby release from liability and hold harmless all persons and corporations supplying this information. A photocopy of this authorization is as valid as the original.
Signed: * Date: *
Attach a resume: 
Brilex Tech is fully committed to equal employment opportunity (EEO) and maintaining a workplace free of discrimination and harassment based on race, gender, religion, age, color, national origin, disability, and other non-merit factors.

Brilex Tech prohibits discrimination in all aspects of its personnel policies, practices, and operations, and relationships with employees and applicants, including, but not limited to, recruitment, hiring, and merit promotion. EOE