New Mexico Chili Dot Com Application
All fields marked with * are required.
First Name:
*
 Last Name:
*
Social Security Number:
*
Address:
*
City:
*
 E-Mail Address:
State:
*
Zip:
*
Phone:
*
XXX-XXX-XXXX		Date of Birth:
MM/DD/CCYY

Miscellaneous Information
NM Driver's License #: Expiration Date:
MM/DD/CCYY		State:
Years of Work Experience:
Have you ever been convicted of a crime or have any charges currently pending?
Felony?
Misdemeanor?

Have you ever refused or failed a drug test?

Have you had a dwi/dui within the last seven years?
Yes No
Yes No
Yes No

Yes No


Yes No
If yes, explain:
Was your license ever suspended/revoked? Yes No
When?
 Where?
Reference Name: Phone Number:
XXX-XXX-XXXX
Current Employer Information
Current Employer: Position:
Dates of Employment...
From:
MM/DD/CCYY
To:
MM/DD/CCYY
Pay:
City: State:
Phone:
XXX-XXX-XXXX		Contact:

Past Employer (1) Information
Past Employer: Position:
Dates of Employment...
From:
MM/DD/CCYY
To:
MM/DD/CCYY
Pay:
City: State:
Phone:
XXX-XXX-XXXX		Contact:
Why did you leave?

Past Employer (2) Information
Past Employer: Position:
Dates of Employment...
From:
MM/DD/CCYY
To:
MM/DD/CCYY
Pay:
City: State:
Phone:
XXX-XXX-XXXX		Contact:
Why did you leave?


I certify that I personally completed this application and that all of the information is true and correct. I authorize NM Chili Dot Com, Gary F. Maricle and any third party employment company to conduct a thorough background investigation in accordance with state and federal law and authorize my previous employers to release any information requested by Gary F. Maricle or any third party employment company and hold them harmless of all liability from the release of said information. Also, in accordance with the provisions of 49 CFR Part 382.405 and 382.413, I hereby authorize and require my previous and/or current employers specifically listed by me on this application to release the results (including any refusal to test) of all drug and alcohol tests taken by me pursuant to the provisions of 49 CFR while in their employment to NM Chili dot Com, Gary F. Maricle, and any third party employment companies whichever means is most expedient.  Submitting this application signifies total agreement to these provisions.