HR Curtis Employee Information Sheet
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First Name *
Last Name *
Email Address *
Email Address (repeat) *
Cell phone number *
Home phone number (if you have one)
Current street address *
City *
State *
Your Date of Birth *
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Social Security # *
Drivers License # *
Court convictions: Have you ever been convicted of an offense other than a minor traffic violation?  *
Court convictions: If you have been convicted of an offense other than a minor traffic violation, please explain:
Emergency contacts (Names and phone numbers) *
Health: Do you have any physical or mental conditions that could affect your job performance? *
Health: If you do have any physical or mental conditions that could affect your job performance, please explain:
Medicine: Are you taking any prescribed or non-prescribed medicines that could affect your job performance? *
Medicine: If you are taking any prescribed or non-prescribed medicines that could affect your job performance, please explain:
Will you be available for after-hours, weekend or holiday work if needed?  *
Are you afraid of heights or confined spaces? *
Personal reference #1: Full Name *
Personal reference #1: Cell Phone # *
Personal reference #1: Relationship to you *
Personal reference #2: Full Name *
Personal reference #2: Cell Phone # *
Personal reference #2: Relationship to you *
Personal reference #3: Full Name *
Personal reference #3: Cell Phone # *
Personal reference #3: Relationship to you *
Level of education *
Social media platform #1 *
For example, Facebook, Twitter, etc.
Social media handle #1 *
The name you use for this social media platform
Social media platform #2 *
For example, Facebook, Twitter, etc.
Social media handle #2 *
The name you use for this social media platform
Please list all the jobs you have held in the past 3 years. Please also include the timeframes of when you have held these jobs.  *
"To the best of my knowledge, all statements on this application are true and correct." (Write your full name below to sign.) *
Today's date *
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