Name

Cell Phone

Email Address

Address

City

State

Zip

Referred By

Position Applied For

Date You Can Start

Desired Salary

Are You Currently Employed? Are You Currently Employed? Yes No

If yes, may we inquire of your present employer? If yes, may we inquire of your present employer? Yes No

Have you ever been employed here before? Have you ever been employed here before? Yes No

If yes, give dates

High School Graduation Year

College Graduation Year

College Degree Received

Vocational Training

Vocational Years of Training

List any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying

Employer Name and Address

Salary

Position

Employed From:

Employed To:

Reason for leaving

Employer Name and Address

Salary

Position

Employed From:

Employed To:

Reason for leaving

List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws." "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws." Yes (checking yes means you acknowledge & give consent) No

eSign (type your name to eSign)

Date Signed

First Name

Middle Name

Last Name

Social Security Number

Date of Birth

Driver's License Number

State of License

Current Address:

City:

Parish/County:

State:

Zip Code:

How long have you lived at your current address?

List all cities, parishes/counties, and states where you have lived in the past 10 years:

Please list all previous legal names, including maiden name, if any and years changed:

Have you ever been convicted of a crime? If yes, please provide details about your conviction including the nature of the offense, date, and in what court/jurisdiction.

I, [applicant name] have applied for employment with ACA. I understand that as a condition for my being considered for employment at the position for which I am applying, I will be required to undergo drug and /or alcohol testing. I willingly agree to this testing and understand that if my test results are positive, I shall not be considered further by ACA for this position. ACA does not tolerate the use of alcohol or non-prescription drugs on company premises or job sites. If an employee is suspected of working while under the influence of illegal drugs and/or alcohol, the employee will be suspended and required to submit to a drug and/or alcohol test. Suspension shall be without pay until the results of the test are obtained by ACA. All employees and prospective employees are hereby notified that test results may be used in arbitration, administrative hearings and court cases arising as a result of the employees drug testing. In all other instances, every reasonable effort will be made by ACA to protect the confidentiality of the information. I hereby authorize any laboratory, physician or medical professional retained by ACA to conduct such testing and to provide the results to ACA. I further release ACA and any person affiliated with ACA and any such institution or person conducting the testing, from liability therefore. I, [applicant name] have applied for employment with ACA. I understand that as a condition for my being considered for employment at the position for which I am applying, I will be required to undergo drug and /or alcohol testing. I willingly agree to this testing and understand that if my test results are positive, I shall not be considered further by ACA for this position. ACA does not tolerate the use of alcohol or non-prescription drugs on company premises or job sites. If an employee is suspected of working while under the influence of illegal drugs and/or alcohol, the employee will be suspended and required to submit to a drug and/or alcohol test. Suspension shall be without pay until the results of the test are obtained by ACA. All employees and prospective employees are hereby notified that test results may be used in arbitration, administrative hearings and court cases arising as a result of the employees drug testing. In all other instances, every reasonable effort will be made by ACA to protect the confidentiality of the information. I hereby authorize any laboratory, physician or medical professional retained by ACA to conduct such testing and to provide the results to ACA. I further release ACA and any person affiliated with ACA and any such institution or person conducting the testing, from liability therefore. Yes (checking yes means you acknowledge & give consent) No

eSignature (type your name to eSign)

Date Signed

Applicant/Employee Name (please print)

"Pursuant to LSA-RS 23:1208 of the Louisiana Workers' Compensation Act, I understand that the failure to answer truthfully any of the below listed questions may result in a fine of not more that Five Hundred Dollars or imprisonment for not more that twelve months, or both. I understand that violating part of this section may result in a forfeiture of compensation benefits under the Louisiana Workers' Compensation Act." "Pursuant to LSA-RS 23:1208 of the Louisiana Workers' Compensation Act, I understand that the failure to answer truthfully any of the below listed questions may result in a fine of not more that Five Hundred Dollars or imprisonment for not more that twelve months, or both. I understand that violating part of this section may result in a forfeiture of compensation benefits under the Louisiana Workers' Compensation Act." Yes (checking yes means you acknowledge & give consent) No

Are you aware of any condition or injury that might impair or limit your ability to work for this company? Are you aware of any condition or injury that might impair or limit your ability to work for this company? Yes No

If yes, please describe the condition or injury.

I have read and fully understand the above. I have read and fully understand the above. Yes (checking yes means you acknowledge & give consent) No

1208.1 Employer's inquiry into employee's previous injury claims: Forfeiture of benefits Nothing in this Title shall prohibit an employer from inquiring about previous injuries, disabilities, or other medical conditions and the employee shall answer truthfully; failure to answer truthfully shall result in the employee's forfeiture of benefits under this chapter. Provided said failure to answer directly relates to the medical condition for which a claim for benefits is made of affects the employer's ability to receive reimbursement from the second injury fund. This section shall not be enforceable unless the written form on which the inquiries about previous medical conditions are made contains a notice advising the employee that his failure to answer truthfully may result in his forfeiture of workers' compensation benefits under R.S. 1308:1. Such notice shall be prominently displayed in bold faced block lettering of no less that ten point type. 1208.1 Employer's inquiry into employee's previous injury claims: Forfeiture of benefits Nothing in this Title shall prohibit an employer from inquiring about previous injuries, disabilities, or other medical conditions and the employee shall answer truthfully; failure to answer truthfully shall result in the employee's forfeiture of benefits under this chapter. Provided said failure to answer directly relates to the medical condition for which a claim for benefits is made of affects the employer's ability to receive reimbursement from the second injury fund. This section shall not be enforceable unless the written form on which the inquiries about previous medical conditions are made contains a notice advising the employee that his failure to answer truthfully may result in his forfeiture of workers' compensation benefits under R.S. 1308:1. Such notice shall be prominently displayed in bold faced block lettering of no less that ten point type. Yes (checking yes means you acknowledge & give consent) No

"Pursuant to LSA-RS 23:1208 of the Louisiana Workers' Compensation Act, I understand that the failure to answer truthfully any of the below listed questions may result in a fine of not more that Five Hundred Dollars or imprisonment for not more then twelve months, or both. I understand that violating part of this section may result in a forfeiture of compensation benefits under the Louisiana Workers' Compensation Act "Pursuant to LSA-RS 23:1208 of the Louisiana Workers' Compensation Act, I understand that the failure to answer truthfully any of the below listed questions may result in a fine of not more that Five Hundred Dollars or imprisonment for not more then twelve months, or both. I understand that violating part of this section may result in a forfeiture of compensation benefits under the Louisiana Workers' Compensation Act Yes (checking yes means you acknowledge & give consent) No

Have you ever had surgery to any part of your body? Have you ever had surgery to any part of your body? Yes No

If yes, please list the part(s) of the body operated on, the type of operation performed, the date of the operation, the name of the facility where the operation was performed and the name, address, and phone number of the doctor performing the surgery.

Have you ever received treatment for your back, neck, knees, or lower extremities from a doctor, chiropractor, therapist, or other health care provider? Have you ever received treatment for your back, neck, knees, or lower extremities from a doctor, chiropractor, therapist, or other health care provider? Yes No

If so, please list name, address and phone number of all doctors, chiropractors, therapist or other health care provider who provided such treatment, the dates of the treatment and the diagnosis provided by the doctor, chiropractors, therapist or other health care provider.

Have you ever had any injury which required you to miss time from work? Have you ever had any injury which required you to miss time from work? Yes No

If yes, please list the type of injury, the amount of time missed from work, whether the condition was fully resolved or if it left you with any impairment, and whether you returned to work.

eSign(type your name to eSign)

By checking "Yes" I acknowledge that I am the individual stated on this application, I have read all contents, and given accurate information. I also consent to the use of this information for background checks. By checking "Yes" I acknowledge that I am the individual stated on this application, I have read all contents, and given accurate information. I also consent to the use of this information for background checks. Yes No