Application for Employment

Record of Education

School Name & Address Course of Study Last Year Completed Graduation Date Diploma / Degree

High School

College

Other

Personal References

Please provide three professional or personal references (not family members).

Reference 1 — Name & Occupation

Phone No.

Reference 2 — Name & Occupation

Phone No.

Reference 3 — Name & Occupation

Phone No.

Military Service Record

Were you in the U.S. Armed Forces?

Yes No

Dates of Duty: From

Rank at Discharge

Duties in service, including special training

Have you taken any training under the G.I. Bill of Rights?

Yes No

Certification & Signature

The facts set forth in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of my personal history and any of the information that I have provided on this application. I hereby authorize any former employer, person, firm, corporation or government agency to answer any and all questions and release or provide any information within their knowledge or records, and I agree to hold any or all of them blameless and free of any liability for releasing any truthful information that is within their knowledge of records.

Applicant Signature (type full name) *

Date Signed *

I certify that all information is true and accurate and I authorize Synergy Security Services, LLC to verify my background and references.

Fields marked * are required. Your application will be securely submitted to our HR team.

Personal Information

Record of Education

Employment History

Personal References

Military Service Record

Certification & Signature