This is a legal document & must be completed prior to any interview.
Incorrect data listed below may be subject to termination, if hired.

Position Applied For: _______________________ Date: _____________

Name: __________________________ Date of Birth: ________________
(Required by Cal U-Rent & allowed by law)

Address: ________________________ Tele. #: ( )________________

City: ____________________________ Tele. # Yours: Yes____ No____

Do You: Rent:_____ Own:_____

Social Security #: ____ - ____ - ________ Expected Wage: ___________

Physical Status:
Height: _______ Weight: _______ Describe Health: ____________________

Domestic Status:
Single: ___ Married: ___ Separated/ Divorced: ___ Living Partner:___

Driver’s License: #: ___________________ State: __________________
Class: A: ___ B: ___ C: ___ Ever had Class A or B: Yes:___No:___

Method of getting to work: Car: ___ Truck: ___ Bike: ___ Other: ___

During the Last Ten Years, Have You Had:
Driving Tickets for: DUI: ___Speeding: ___Reckless Driving: ___
Back Problems: ___ Problems Lifting: ___
Physical Defect: ___ Worker’s Comp Claims: ___ For What: _________
Criminal Conviction: ___ Problems: Drinking: ___ Health: ___

Do You: Can You:
Drink: ___ Work Weekends: ____
Object to Drug Testing: ___ Start Work Immediately: ___

Have You:
Made any Time Commitments that would affect work: ___

Taken Drugs or Marijuana: ___ Been in Jail: ___

Is there anything that would affect your work in any way: ___
Explain:
____________________________________________________________

____________________________________________________________

____________________________________________________________

CURRENT or LATEST JOB: (Use months & Years for working periods)

Starting Date: __________ Ending Date: __________ Supervisor’s Name: ___________

Business Name: ____________________Telephone #: (_______)___________________

Job Description: _______________ Wages: Starting: $_____/ Hr. Ending: $ _____/ Hr.

Reason for Leaving: _______________________________________________________
===============================================================
Cal U-Rent Use Only:
Starting Date: __________ Ending Date: __________ Supervisor’s Name: ___________

Business Name: ____________________Telephone #: (_______)___________________

Job Description: _______________ Wages: Starting: $_____/ Hr. Ending: $ _____/ Hr.

Reason for Leaving: _______________________________________________________

Cal U-Rent Use Only:
Starting Date: __________ Ending Date: __________ Supervisor’s Name: ___________

Business Name: ____________________Telephone #: (_______)___________________

Job Description: _______________ Wages: Starting: $_____/ Hr. Ending: $ _____/ Hr.

Reason for Leaving: _______________________________________________________

Cal U-Rent Use Only:
Starting Date: __________ Ending Date: __________ Supervisor’s Name: ___________

Business Name: ____________________Telephone #: (_______)___________________

Job Description: _______________ Wages: Starting: $_____/ Hr. Ending: $ _____/ Hr.

Reason for Leaving:
____________________________________________________________

____________________________________________________________

____________________________________________________________

Cal U-Rent Use Only:

MILITARY HISTORY:

Did you serve in any branch of the Armed Forces: ___ Branch: ________________

Year of Discharge: _______ Honorable Discharge: ___Any future commitment: ___

Any Special Training: ___________________________________________________

EDUCATION & TRAINING:

High School Graduate: ___ Attended College: ___ Where: _____________________

Trade School Graduate: ___ Where: _______________________________________

Special Training or Qualifications: _________________________________________

The information that you have provided above is confidential and will not be divulged
to any governmental agency, individual or firm without your express consent.

The information that I have provided above is true and correct to the best of my
knowledge and that no information has been omitted or concealed. I understand
that false statements made on this application constitute fraud and is sufficient
cause for immediate dismissal and may be cause for criminal action.

I hereby release Cal U-Rent from any liability or damages resulting from discovery
communications pertaining to this employment. I realize that prior friends, employers,
governmental agencies and others may be asked information.

Signature (required):


____________________________________________________________