Applicant InformationFirst Name *Middle Name *Last Name *Date *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwePhone *Email Address *Date of Birth *Drivers License # or ID card #: *License or ID Expiration Date.: *Are you a citizen of the United States? *YesNoIf no, are you authorized to work in the U.S.? YES NO *YesNoHave you ever worked for this company? *YesNoIf yes, when? *Have you ever been convicted of a felony or misdemeanor? *YesNoIf yes, explain: *Are you a non-commissioned officer ? *YesNoAre you a commissioned officer? *YESNODo you own your own transportation? *YESNODo you own a firearm for on duty use? *YESNODo you have any type of mental illness? *YESNOIf yes, explain: *Are you taking or have taken medication for a mental disorder? *YESNOIf yes, explain: *Are you able to perform the essential function of the job for which you are applying? *YESNOIf no, explain: *EducationHigh School: *Address: *Did you graduate? *YesNoDate: *College: *Did you graduate? *YesNoDate: *Do you speak any languages other than English? *YESNOIf yes, list them: *ReferencesPlease list three professional references.Full Name: *Relationship: *Company: *Phone: *Address: *Full Name: *Relationship: *Company: *Phone: *Address: *Full Name: *Relationship: *Company: *Phone: *Address: *Emergency ContactFull Name: *Relationship: *Address: *Phone: *Previous EmploymentCompany 1: *Phone: *Address: *Supervisor: *Job Title: *Supervisor Email : *Position & Duties: *From: *To: *Reason for Leaving: *May we contact your previous supervisor for a reference? *YESNO Company 2: *Phone: *Address: *Supervisor: *Job Title: *Supervisor Email : *Position & Duties: *From: *To: *Reason for Leaving: *May we contact your previous supervisor for a reference? *YESNO Company 3: *Phone: *Address: *Supervisor: *Job Title: *Supervisor Email : *Position & Duties: *From: *To: *Reason for Leaving: *May we contact your previous supervisor for a reference? *YESNOMilitary ServiceBranch:From:To:Rank at Discharge:Type of Discharge:If other than honorable, explain:Disclaimer and SignatureIf hired, I understand that I must give a two week notice, or all remaining unpaid work hours will be paid at the minimum wage at the time of separation from CSA.(Initials)Upon resignation or termination, I understand that I must comply with CSA’s request for the return of all issued uniforms and equipment with three days. Failure to comply will constitute theft and be reported the Law Enforcement and the State Board. (Initials)I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment, and that the information contained in this application is true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application, or on any document used to secure employment shall be grounds for rejection of this application, or for immediate termination if I am employed, regardless of the time elapsed before discovery.(Initials)I hereby authorize CSA to investigate my references, work record, education, and other matters related to my suitability for employment, and further authorize the reference I have listed to disclose to CSA all letters, reports, and other information related to my work records, without providing prior notice to me of such disclosure. In addition, I hereby release CSA, my former employers and all other persons, corporations, partnerships and associations from all claims, demands or liabilities arising out of or related to such investigation or disclosure.(Initials)Signature:Start signing your signature hereYour browser does not support e-Signature field.Date: Send Message