LDSI, Inc.

508 West 5th Street, Suite 125

Charlotte, North Carolina 28202

Application for Employment

Date: ______Social Security Number: ______

Last Name: ______First Name: ______

Address: ______

City: ______State: ______Zip Code: ______

Home Phone: ______Business Phone: ______

Position Sought: ______Desired Wage: ______

Are you available for full-time work? ______

Will you work overtime if asked? ______

When will you be available to begin work? ______

Are you available for out of town work on a regular basis? ______

Employment Experience

Present or most recent position:

Company Name: ______Telephone: ______

Address: ______

Name of Supervisor: ______Wages: ______

Employed (State month and year): From ______To ______

State Job Title and Describe Your Primary Duties: ______

Reason for Leaving: ______

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Prior position #1:

Company Name: ______Telephone: ______

Address: ______

Name of Supervisor: ______Wages: ______

Employed (State month and year): From ______To ______

State Job Title and Describe Your Primary Duties: ______

Reason for Leaving: ______

Prior position #2:

Company Name: ______Telephone: ______

Address: ______

Name of Supervisor: ______Wages: ______

Employed (State month and year): From ______To ______

State Job Title and Describe Your Primary Duties: ______

Reason for Leaving: ______

Prior position #3:

Company Name: ______Telephone: ______

Address: ______

Name of Supervisor: ______Wages: ______

Employed (State month and year): From ______To ______

State Job Title and Describe Your Primary Duties: ______

Reason for Leaving: ______

May we contact the employers listed above? ______

If not, please list any that you do not want contacted and reason? ______

Education:

High School:

Name: ______Location: ______

Course of Study: ______Did You Graduate: ______

Years Completed: ______Degree/Diploma: ______

Business/Trade/Technical:

Name: ______Location: ______

Course of Study: ______Did You Graduate: ______

Years Completed: ______Degree/Diploma: ______

College:

Name: ______Location: ______

Course of Study: ______Did You Graduate: ______

Years Completed: ______Degree/Diploma: ______

Graduate/Professional:

Name: ______Location: ______

Course of Study: ______Did You Graduate: ______

Years Completed: ______Degree/Diploma: ______

Please list any other special training or skills: ______

Important Please Read

  • I hereby affirm that the information provided on this application (and accompanying transcript and resume, if any) is true and complete to the best of my knowledge and agree that falsified or misleading information or significant omissions may disqualify me from further consideration and may be cause for dismissal if discovered at a later date.
  • I hereby authorize former and present employers and others to give or verify any information they have regarding me or my employment with them, and I release them and their companies from any liability for damage resulting wherefrom.
  • I also understand that any employment which may result with LDSI, Inc., can be terminated, with or without cause and with or without notice, at any time, at the option of either LDSI, Inc., or myself.
  • I understand that offers of employment are conditioned upon successful passing of a drug test as scheduled by LDSI, Inc.
  • We are an Equal Employment Opportunity Employer. Consideration for employment is based solely on individual qualifications, without regard to race, marital status, religious creed, color national origin, ancestry, physical handicap, medical condition, sex, sexual orientation, age, or any other protected category recognized by applicable federal, state and local laws.

Signature: ______

Date: ______

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