RS Express | Employment Application

Please print this page and mail or bring in to: Matt Kilburn, RS Express, 164 Kneeland St. Boston MA 02111

RS Express, Incorporated Application for Employment

Today's Date:_______/______/_______

Name (last name first):____________________________________________________

Address:_______________________________________________________________

City/State/Zip Code:______________________________________________________

Telephone Number:_______________________ Pager Number:____________________

Social Security Number:_____________________ Referred by:___________________

Position Desired:______________________ Proposed Start Date:______/______/_____

Salary Desired:________________

Are you currently employed?:______If so, may we enquire of your present employer?_______

Have you ever applied to us before?_________ When?______/______/_____

Education History:

Name and Location of School:

High School: ____________________Years attended:________ Did you graduate?_______

College: ________________________________________ Years attended:____________

Subjects studied:_____________________________________ Did you graduate? _______

Trade, Business or Correspondence School: __________________ Years attended:_______

Subjects studied:_____________________________________ Did you graduate? _______

General Information:

Subjects of Special Study/Research Work or Special Training/Skills: ____________________

_________________________________________________________________________

US Military or Naval Service: __________________________________ Rank: ___________

Former Employers:

Date (From/To-MM/YY): Name and address of Employer: Salary: Position: Reason for leaving:

___________________ | _____________________________________ | ____________ | ____________ | _______________________

References:

Give below the names of three people not related to you, whom you have known for at least one year:

Name: ______________________ Address: ____________________________________

Business: ___________________ Phone #: ________________ Years Known: _________

Name: ______________________ Address: ____________________________________

Business: ___________________ Phone #: ________________ Years Known: _________

Name: ______________________ Address: ____________________________________

Business: ___________________ Phone #: ________________ Years Known: _________

Authorization:

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

Date: ________________ Signature: ________________________________________

Interviewed by: ____________________________________ Date: ________________

RS Express is an Equal-Opportunity Employer

__________________________ Do not write below this line __________________________

Remarks:

______________________________________________________________________

Neatness: ___________________ Character: _________________________________

Ability: ______________________ Personality: ________________________________

Hired: ______________________ Position: __________________________________

Will Report: __________________ Salary/Wages: ______________________________

Questions? Call 617.350.0247 between 7am and 8pm Monday- Friday.

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