Referral Source

How did you learn of position(s) at Las Cumbres?

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Employee

Relative

Government Employee Agency

Other (Please provide details below)

Name *

First Name

Last Name

Address *

List your present Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Are you related to anyone employed at Las Cumbres?

Yes

No

Have you ever been employed at Las Cumbres before?

Yes

No

If yes give dates - From

MM

DD

YYYY

To

MM

DD

YYYY

Are you legally eligible for employment in the US? *

Yes

No

Date Available for work

MM

DD

YYYY

Type of employment desired (check all applicable)

Full-time

Part-time

Temporary

Seasonal

Educational Co-op

Will you relocate if the job requires?

Yes

No

Will you travel if job requires?

Yes

No

Are you able to meet the attendance requirements of the position? *

Yes

No

Will you work overtime if required? *

Yes

No

Phone for Most Recent

(###)

###

####

May we contact for a reference?

Yes

No

Dates Employed - From

MM

DD

YYYY

To

MM

DD

YYYY

Phone for 2nd Most Recent Employer

(###)

###

####

May we contact for a reference?

Yes

No

Date Employed - 2nd Employer - From

MM

DD

YYYY

To

MM

DD

YYYY

Phone for 3rd Employer

(###)

###

####

May we contact for a reference?

Yes

No

Dates Employed From - 3rd Employer

MM

DD

YYYY

To

MM

DD

YYYY

Phone - Reference 1

(###)

###

####

Phone - Reference 2

(###)

###

####

At-Will and Acknowledgement *

I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer’s service, whenever it is discovered. I give the employer the right to contact and obtain information from all references, employers, education institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering, and using such information and all other persons, corporation, or organizations for furnishing such information. The employer does not unlawfully discriminate in employment and no questions on this application is used for the purpose for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state, or federal law. This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that o representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand that is the company’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for a reasonable accommodation required by the ADA. I understand that if driving is an essential function of the job, I need to provide proof of a clean driving record and proof of insurance. I further understand that employment is contingent upon successful completion of a physical examination, drug screening, criminal records check (Physician must be a qualified Las Cumbres contractor). I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

I Agree

I Disagree

Date *

MM

DD

YYYY

You may release the following

Dates of Employment

Positions Held

Salary/Hourly Wage

Reason for Leaving

Eligibility for Rehire

Educational Institution

Years of Attendance

Degree Obtained

Transcript

Date

MM

DD

YYYY

Date

MM

DD

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