Personal Information

Emergency Contact(s)Position Applying For

Availability

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

Please indicate the days of the week as well as the earliest and latest times that you are available for work.

Preferences

*In order to be able to provide transportation or run errands, you will be required to have a valid driver’s license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required.

Job Related Skills

Work History

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Security

References

Disclaimer & Signature

CERTIFICATION AND RELEASE

I certify that I have read and understand the applicant note on page one(1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/ or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Nagomi, Inc., and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.