Rackley Technologies, LLC
Employment Application
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statues, regulations and ordinances.

Application Date: 12/21/2024
PERSONAL INFORMATION

First Name:
Middle Name:
Last Name:
Present Street Address:
Present Mailing Address:
Previous Address: (if less than 12 months)
City:
State:
Zip:
Phone:
E-Mail:
Are you 18 years or older?	YES NO
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?	YES NO

EMPLOYMENT DESIRED

Position:
Type of Position:	Full Time Part Time Contractor
Are you willing to travel?	Yes No
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?	Yes No
If overtime work is required periodically, does this pose a problem for you?	Yes No
Date you can start
Salary Desired
Are you employed now?	YES NO
Have you ever been convicted of a crime and/or released from confinement following a conviction for any criminal offense?	Yes No
If Yes, give date, place and nature of each such conviction.
Are you presently charged with any violation of the law?	Yes No
If yes, give date, place and nature of each such charge.

Please attach your current Resume.

Attach a Resume File:

CONDITIONS
By selecting "Submit Application", I certify that the information in this application is true and complete for all
practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later
it is found that the information is significanlty untrue, incomplete, or misrepresented, I understand and
agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to
employment, and that I am subject to immediate discharge without recourse.

I understand that an investigative report may be made by a consumer reporting agency
to include information as to my character, general reputation, personal characteristics, and
mode of living, whichever may be applicable. If such an investigative report is made, I
understand that I will receive notice that such report has been requested for a complete
and accurate disclosure of additional information concerning the nature and scope of the
investigation.

I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE
WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A
GRATUITOUS STATEMENT OF FACILITY POLICIES.

I understand that the facility reserves the right to require its employees to submit to blood test or
urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases)
or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis,
blood test or search, when requested to do so, may result in termination of my employment.

I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY
EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY
WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME,
WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE. I ALSO UNDERSTAND THAT
THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT
WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE
ADMINISTRATOR OF THE FACILITY.

RELEASE:
I hereby authorize any prior employers to provide such information concerning my employment
with them as may be requested, and also authorize the Registrar/Placement Office of all
educational institutions attended to release an official copy of my transcript and if available,
faculty appraisals. I also authorize any appropriate licensing board to release full information
concerning my licensure status and my licensure history.

AUTHORIZED USE ONLY

Category:
Remarks:
Ranking:
Status:
Hire Date:
Position:
Starting Wage:
Starting Date: