• Installation
• Repair Services
• Administrative
• Management
• Sales & Marketing

First Name
Last Name
Middle Name
Street Address
City
State
Zip
Phone
Email

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I am at least 18 years of age.

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I have a valid Pennsylvania drivers license.

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Please state the highest level of education completed SELECT ONE GED High School Diploma Bachelors Degree Masters Degree Doctorate Degree

Employed from	to
Name of Employer
Supervisor Name
Phone
Street Address
City
State
Zip
Reason(s) for leaving

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Employed from	to
Name of Employer
Supervisor Name
Phone
Street Address
City
State
Zip
Reason(s) for leaving

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Employed from	to
Name of Employer
Supervisor Name
Phone
Street Address
City
State
Zip
Reason(s) for leaving

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May Central State Distributors contact your present employer? Yes No

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Have you had a work related injury that required you to miss work? Yes No

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Include Name, Address, and Phone Number (Please do not use relatives.)

I expressly authorize Central State Distributors to contact any of my prior employers listed above. I also expressly release those prior employers and Central State Distributors from any and all liability arising from their giving the information about my employment history.

I authorize investigation and verification of all statements contained in this application submission. I also agree to execute as a condition of employment any additional written authorizations necessary for Central State Distributors to secure access to records pertaining to this information. I understand that misrepresentation or omission of facts called for is cause for dismissal, whether or not such misrepresentation is discovered before or after I begin my employment.

I have read and agree with these terms.

I authorize any present employer or supervisor, past employer or supervisor, college, university or other institution of learning, administrator, law enforcement agency, state agency, federal agency, finance bureau/office, credit bureau, collection agency, private business, military branch or the National Personnel Record Center, personal reference, and/or other persons, to give records of information they may have concerning my criminal history, motor vehicle history, earnings history, credit history, health, character and employment records or any other information requested to Central State Distributors/Allison Door Sales. In addition, I understand and authorize any random or post incident/accident drug testing that may be requested by employer.

I have read and agree with these terms.