Delta Foremost

= Required


1. Employment with Delta Foremost Chemical Corp.
Position Requested Salary Requirement Date Available Days and Hours Available
2. Personal Information
Last Name First Middle Social Security Number
Home Phone Cell Phone Other Phone Email Address
Current Address
Street Address City State Zip Start Date End Date
Previous Address (if less than 5 years at current)
Street Address City State Zip Start Date End Date
3. Transportation Information
What make of car will you use for work? What is the model? What is the year? What is the mileage?
In what state was your driver license issued? What is your driver license ID Number? Do you have Auto Insurance? Yes No
How much coverage do you have for collision? How much coverage do you have for public liability?
4. Military Information
1.Have you ever been in the Armed Forces? If yes, what was your rank? Yes No
2.If yes to #1, what date did you enter and when were you discharged?
5. Education History
High School Name Location Degree or Major GPA Start Date End Date
University/College 1 Name Location Degree or Major GPA Start Date End Date
University/College 2 Name Location Degree or Major GPA Start Date End Date
6. Work, Professional, or Personal Skills
7. Employment History
Current or Previous Employer 1
Company Position/Title Start Date End Date
Address Reason for Leaving (Please be Specific) Salary/Gross Wage
May we contact this employer? If no, please explain: Contact Name Contact Phone Contact E-mail
Explain positions held, job duties, skills, advancements, or other relevant information about this job:
Previous Employer 2 (if less than 5 years)
Company Position/Title Start Date End Date
Address Reason for Leaving (Please be Specific) Salary/Gross Wage
May we contact this employer? If no, please explain: Contact Name Contact Phone Contact E-mail
Explain positions held, job duties, skills, advancements, or other relevant information about this job:
Previous Employer 3 (if less than 5 years)
Company Position/Title Start Date End Date
Address Reason for Leaving (Please be Specific) Salary/Gross Wage
May we contact this employer? If no, please explain: Contact Name Contact Phone Contact E-mail
Explain positions held, job duties, skills, advancements, or other relevant information about this job:
8. Other Skills
1.Do hold or possess any professional licenses or certificates? If yes, please explain: Yes No
2.Do you have any accreditations? If yes, please explain: Yes No
3.Do speak any languages other than English? If yes, please explain: Yes No
4.Do have any specialized skills? If yes, please explain: Yes No
5.Are you involved in any special organizations? If yes, please explain: Yes No
9. Personal References, No Employers or Relatives
Name Company Phone Email Relationship
Name Company Phone Email Relationship
Name Company Phone Email Relationship
10. Emergency Contact
Name Phone Email Relationship
Street Address City State Zip
11. Background Questionnaire
1.Are you a U.S. Citizen? If no, please explain: Yes No
2.Do you have a legal right to work in the U.S.? If no, please explain: Yes No
3.Have you ever worked for this company before? If yes, please explain: Yes No
4.Do you have any relatives that work for this company? If yes, please explain: Yes No
5.Do you have any special needs or requirements? If yes, please explain: Yes No
6.Have you ever been convicted of a crime? If yes, please explain: Yes No
7.Are you bondable? Yes No
12. Why do you feel that you are a good candidate for this position?
We would very much appreciate your input:
13. Other Information
How did you hear about this job?
Please include any other information that you feel is necessary for the evaluation of this application:

By signing below, I hereby authorize Delta Foremost Chemical Corp., their employees, their representatives, and their agents, to contact any and all people, businesses, and other entities listed within this application for the purpose of investigating and verifying the accuracy of the information provided in this application. I authorize the release of personal and business information from previous or current employers, or any other companies and/or representatives listed within this application, in pursuit of this investigation. I understand that this investigation is for screening purposes for potential employment with Delta Foremost Chemical Corp., and that allowing the release of this information does NOT guarantee employment.


Should I be employed by Delta Foremost Chemical Corp., I authorize its representatives to furnish information regarding my employment at Delta Foremost Chemical Corp. if such information is requested in the future. I release Delta Foremost Chemical Corp. and its authorized representatives from any liability for any damage whatsoever resulting from furnishing this information.


I certify that information I have provided in this application is true, complete, and to the best of my knowledge at the time this application was completed. I understand that if am offered and accept employment with Delta Foremost Chemical Corp. and it is discovered at a later time that any of information provided in this application is incorrect, it may be considered grounds for immediate termination of employment. I understand that any potential employment opportunities acquired with Delta Foremost Chemical Corp. will be for no definite term and that I, or Delta Foremost Chemical Corp., have the right to terminate any such employment relationship at any time, with or without cause, and with or without advance notification.


I authorize Delta Foremost Chemical Corp. to obtain one or more investigative consumer credit report(s), which may include, but not limited to, public information, credit history, residence history, landlord/tenant court record search, criminal record search, and registered sex offender search, for the purpose of evaluating my employment application. These reports contain information compiled from sources believed to be reliable, but the accuracy of these reports is not guaranteed to be 100% correct. Consumer reports may be obtained from any of the following consumer reporting agencies:
Equifax, E.C.I.F., P.O. Box 740241, Atlanta, GA. 30374-0241, 800-685-1111 | Trans Union, Regional Disclosure Center, 1561 Orangethorpe Ave., Fullerton, CA. 92631, 714-738-3800 | Experian (TRW), Consumer Assistance, P.O. Box 949, Allen, TX. 75002, 888-397-3742

I understand that I am entitled by law to receive at least one free copy per year of my consumer report(s) from any of the previously noted companies, and can do so visiting http://www.annualcreditreport.com or by contacting any of these companies directly. If any of these reports are obtained and used as part of this investigation, I also have the right to receive a copy of any such records, and they will be provided to me upon request.


I understand that I can find a summary of my rights under the Fair Credit Reporting Act by visiting: http://www.ftc.gov/credit or by writing: Consumer Response Center, Room 130-A | Federal Trade Commission | 600 Pennsylvania Avenue N.W. | Washington D.C. 20580

I hereby release Delta Foremost Chemical Corp. harmless of any liability for any damages resulting from any improper collection, storage, usage, theft, and/or distribution of these consumer reports, and any other information obtained as part of, or as a result of, this employment application.


Applicant Signature Date

By typing your name above and submitting this form, the same legal status is held as a handwritten signature.
Misleading information on this application is considered FRAUDULENCE and is grounds for immediate termination of employment.



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