Kgid Proposal Form – Fill Out and Use This PDF

Answer only if position requires.

Do you possess a valid driver’s license?

 Yes  No

If so, license expires

Class

Restrictions (if any)

For positions that require typing:

I certify that I can type at a speed of

WPM.

Have you ever been convicted of, pled guilty or nolo contendre to, or been granted deferred

adjudication for a felony, misdemeanor, (excluding juvenile adjudication), or any lesser crime

other than a minor traffic infraction?

 Yes  No

Have you ever been disciplined in your employment related to workplace violence?

 Yes  No

Do you presently use illegal drugs?

 Yes  No

Have you ever been employed by KGID?

 Yes  No

If yes, please provide the following information:

Department

Position Title

Dates of Employment

Reason for Separation

Are you related to anyone who is currently employed by KGID?

 Yes  No

If yes, please provide the following information:

Related person’s name

Department

Relationship

July 2006

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POOL/PACT Human Resources

May we contact all employers listed?

(Attach a list of any exceptions with an explanation.) ......  Yes  No

Present Employer

Present Position

Address

From (Mo/Yr)

To (Mo/Yr)

City

 Full-Time (30+ hrs/wk)

 Part-Time (<30 hrs/wk)

State

Zip Code

Salary

Supervisor’s Name/Title

Telephone ( )

Related Duties

Employer

Position

Address

From (Mo/Yr)

To (Mo/Yr)

City

 Full-Time (30+ hrs/wk)

 Part-Time (<30 hrs/wk)

State

Zip Code

Salary

Supervisor’s Name/Title

Telephone ( )

Related Duties

Employer

Position

Address

From (Mo/Yr)

To (Mo/Yr)

City

 Full-Time (30+ hrs/wk)

 Part-Time (<30 hrs/wk)

State

Zip Code

Salary

Supervisor’s Name/Title

Telephone ( )

Related Duties

July 2006

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POOL/PACT Human Resources

Employer

Position

Address

From (Mo/Yr)

To (Mo/Yr)

City

 Full-Time (30+ hrs/wk)

 Part-Time (<30 hrs/wk)

State

Zip Code

Salary

Supervisor’s Name/Title

Telephone ( )

Related Duties

Employer

Position

Address

From (Mo/Yr)

To (Mo/Yr)

City

 Full-Time (30+ hrs/wk)

 Part-Time (<30 hrs/wk)

State

Zip Code

Salary

Supervisor’s Name/Title

Telephone ( )

Related Duties

July 2006

Page 4 of 6

POOL/PACT Human Resources

_____

All offers of employment and all information regarding compensation and other terms and conditions of

employment will be made in writing. Verbal statements may not be relied upon.

_____

This application is the property of KGID and will become part of my personnel file if I am hired.

_____

I authorize KGID to contact any employer or individual that I have listed on my employment application

and/or résumé or mentioned during job interviews to obtain from them any relevant information

regarding my previous employment, military service, criminal history, characteristics or traits necessary

for job performance, or other relevant qualifications for employment and/or continued employment with

KGID. In addition, I authorize KGID to conduct a background search which includes criminal history

and military history. In addition, if the position for which I am applying requires driving a vehicle, I

authorize KGID to conduct a Department of Motor Vehicles (DMV) search. If the position for which I

am applying involves contact with minors or with any persons having diminished capacity to care for

themselves, a search of government sex offender registries may be conducted. I further authorize KGID

to contact any institution and/or licensing authority to verify my possession of education, licenses, and/or

certificates which may qualify me for employment.

_____

In exchange for KGID’s consideration of my employment application, and/or any continued employment

with KGID, I authorize anyone possessing information to furnish it to KGID upon request, and I release

the organizations and all individuals providing the information or acquiring the information, including

KGID, from all claims, liability, and damages whatsoever claimed to be related to furnishing, obtaining,

or using said information. This release applies to, but is not limited to, claims for defamation, libel,

slander, infliction of emotional distress, and interference with current or prospective economic relations.

_____

I further understand this consent will apply during the entire course of my employment with KGID

should I obtain such employment. I understand and agree this consent shall remain in effect indefinitely.

_____

I hereby certify that all statements made in this application are true. I understand that any false statement

of material facts herein may cause forfeiture on my part of all rights to any employment with KGID. I

understand that any misrepresentation, falsification, or material omission of information may result in my

failure to receive an offer, or if I have been hired, in my dismissal from employment regardless of length

of employment. I understand that neither this document nor any offer of employment from KGID

constitutes an employment contract unless a specific contract document to that effect is executed. I agree

to undergo any job-related physical examination and drug screening upon conditional offer of

employment. I further understand and agree that this paragraph applies to any information supplied by

me at a later date as part of this application.

Additionally, my signature below certifies that the information provided is true and correct to the best of my

July 2006

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POOL/PACT Human Resources

Signature of Applicant

Date

July 2006

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POOL/PACT Human Resources