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TOPEKA, KS 785-232-1015 - LAWRENCE, KS 785-380-0488

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TOPEKA,KS

LAWRENCE, KS

Location

1500 N 3rd St. Lawrence, KS 66044
123 SE 21st St, Topeka, Kansas 66612

Contact Heartland Recovery

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Phone

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Employment Application

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Full Name:

First

Middle

Last

Date:

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Address:

Street Address:

Apartment/Unit #

City

State:

Phone:

Email:

Date Available:

Social Security No.:

Desired Salary:

Position Applied for:

Are you a citizen of the United States?

Yes

No

If no, are you authorized to work in the U.S.?

Yes

No

Have you ever worked for this company?

Ye

No

If yes, when?

Have you ever been convicted of a felony?

Yes

No

If yes, explain:

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Education

High School:

Address:

From:

To:

Did you graduate?

Yes

No

Diploma:

College:

Address:

From:

To:

Did you graduate?

Yes

No

Degree:

Other:

Address:

From:

To:

Did you graduate?

Yes

No

Degree:

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References

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Please list three professional references.

Full Name:

Relationship:

Company:

Phone:

Address:

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Full Name:

Relationship:

Company:

Phone:

Address:

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Full Name:

Relationship:

Company:

Phone:

Address:

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Previous Employment

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes

No

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Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Ye

No

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Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes

No

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Military Service

Branch:

From:

To:

Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

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Disclaimer and Signature

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I certify that my answers are true and complete to the best of my knowledge.

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If this application leads to employment, I understand that false or misleading information in my application or

interview may result in my release.

Signature:

Date:

New Employee

New Employee

turning Employee: Year last employed

Federal Drivers Privacy Protection Act Authorization to Obtain Motor Vehicle Report

Federal Drivers Privacy Protection Act Authorization to Obtain Motor Vehicle Report

For the sole purpose of the determination and evaluation of my motor vehicle operating record and pursuant to the State and Federal regulations of compliance, I (Name of Employee)

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authorize Harding Brooks Associates LLC to obtain my Motor Vehicle Record for insurance underwriting/eligibility purposes. I understand that this record may contain personal information* in addition to any/all driver violations and/or accidents, which may be on record through the Department(s) of Motor Vehicles. I also authorize release of this insurance underwriting/eligibility information to my employer. (or proposed employer.)

Signature of Employee (or potential employee)

Name (Printed)

Drivers License Number

State

Date of Birth

Street Address & Mailing Address

City

State

Zip

Date Signed:

*Personal information means information that identifies an individual including an individual's photograph, driver identification number, name, address and telephone number.

*Personal information means information that identifies an individual including an individual's photograph, driver identification number, name, address and telephone number.

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SHAWNEE COUNTY SHERIFF'S OFFICE (2020)

TOW SERVICE PROVIDER

APPLICATION/BACKGROUND/RECORD CHECK FORM

****(Please Email to Lt. Vest)****

Full First Name:

Middle:

Last:

ALIAS NAMES (maiden, nickname):

E-Mail

Address:

City:

State

Zip:

Contact Phone Number(s): Cell:

Office:

DATE OF BIRTH:

SSN:

SEX:

RACE:

DRIVERS LICENSE NUMBER:

STATE:

TYPE:

NAME OF TOW TRUCK COMPANY (s):

POSITION WITH COMPANY:

Are you currently being investigated for a crime or do you have any felony arrests or convictions?

Yes

No

If yes, please explain (use reverse side if necessary):

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TOPEKA

LAWRENCE

Get A Quote CALL TOPEKA CALL LAWRENCE

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- We Are Hiring

Contact Us

TOPEKA,KS
785-232-1015
LAWRENCE, KS
785-380-0488

1500 N 3rd St. Lawrence, KS 66044
123 SE 21st St, Topeka, Kansas 66612

Business Hours

Mon - Sun: Open 24 Hours

Office Hours
Mon - Fri 8:00 AM - 5:00 PM

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