PERSONAL INFORMATION

Name: First  Middle  Last  Application Date: 

Social Security Number: --  Home Phone Number: --

Other Phone Number: -- 

Over the age of 18? Yes No		U.S. Citizen 		Registered Alien 

RESIDENCES -  List residences for the last five (5) years starting with the most recent.

City (or Town) State 	Zip Code 

From:  To: 

City (or Town) State 	Zip Code 

From:  To: 

City (or Town) State 	Zip Code 

From:  To: 

POSITION APPLIED FOR: Security Officer 	Strike Guard    Full Time     Part Time

Have you completed an application with Victory Security Agency previously? Yes   No 

Do you object to wearing a uniform? Yes   No 

Are you willing to work overtime when needed?  Yes   No 

Are willing to work shift work?  Yes   No 

TRANSPORTATION    Public     Own Personal Vehicle     Valid Pa Driver's License

EDUCATION - List all schools, including any special training schools

		Name of School and Address 	     Last Year Completed  Graduate 	  Course of Study  

ELEMENTARY         Yes  No  

HIGH SCHOOL         Yes  No  

College             Yes  No  

Other               Yes  No  

Are you known to schools/references by another name? Yes   No 

If yes by what name: 

MILITARY SERVICE: Branch  Date Entered:  Date Discharged: 

Type of Discharge Received: 

Reserve/National Guard Status: Active    Inactive 

CHARACTER REFERENCES - Give full names of three (3) people who have known you for at least five (5) years. 

Do not give former employers or relatives:

Name:  Address:  City: 

State:  Zip Code:  Phone #: 

Name:  Address:  City: 

State:  Zip Code:  Phone #: 

Name:  Address:  City: 

State:  Zip Code:  Phone #: 

ADDITIONAL QUALIFICATIONS

First Aid  CPR Certified  EMT Certified  Weapon Certified  Bonded: Yes  No 

Are you able to perform the essential functions for the position for which you are applying? Yes  No 

	If no, explain: 

EMPLOYMENT HISTORY: List all periods of employment for the past ten (10) years, starting with the most recent employer

work backwards. Any periods of unemployment must be noted.

Dates: From:  To:  Employer:  Position Held: 

Address: City:  State:  Zip Code

Rate of Pay:  Supervisors Name:  Reason For Leaving:

Dates: From:  To:  Employer:  Position Held: 

Address: City:  State:  Zip Code

Rate of Pay:  Supervisors Name:  Reason For Leaving:

Dates: From:  To:  Employer:  Position Held: 

Address: City:  State:  Zip Code

Rate of Pay:  Supervisors Name:  Reason For Leaving:

Dates: From:  To:  Employer:  Position Held: 

Address: City:  State:  Zip Code

Rate of Pay:  Supervisors Name:  Reason For Leaving:

Dates: From:  To:  Employer:  Position Held: 

Address: City:  State:  Zip Code

Rate of Pay:  Supervisors Name:  Reason For Leaving:

Are you employed at the present time? Yes  No   May we contact your present employer? Yes  No 

Are you on lay-off and subject to re-call? Yes   No 

Have you ever been convicted of a crime by a civilian or military court?  Yes  No  If yes, list convictions and state circumstances: 

State laws prohibit the employment of security officers with certain types of convictions. In addition, state

laws require a comprehensive evaluation of persons entering private security. This includes a criminal record 

search. Employment may be terminated if a criminal record is found.

Please write a paragraph of 50 word or more explaining why you are interested in working in security. Include 

your likes and dislikes: 

D

DATE OF BIRTH: (OPTIONAL)	

The Age Discrimination in Employment Act prohibits discrimination on the 

 basis of age with respect to individuals who are at least 40 years of age. You must be 18 years of age to be 

considered for employment.

HEALTH: Many health-related problems are classified as handicaps. State and Federal laws prohibit discrimination 

based on the handicap of an otherwise qualified applicant. Upon being offered employment, your medical history 

will be reviewed. You may be asked to take a physical examination. You will be assigned to only those jobs that 

you are physically able to perform. Reasonable accommodations will be made. For your information, many state laws 

prohibit the employment of security officers who have mental or nervous disorders. Also, certain positions, 

by terms of our contracts, set standards for hearing, vision, speech, walking, lifting and other health related areas.

You may choose to discuss areas of concern prior to completion of the employment process.

In consideration of the employment and wages to be paid to me by the Company, I make the following declarations:

I authorize investigation of all matters contained in this application and agree that if, in the judgement of the

Company, any misrepresentation has been made by me herein, or if the results of such investigation are not 

satisfactory, any offer of employment made by the Company may be withdrawn, or my employment with the Company may 

be terminated immediately without any obligation or liability to me, other than for payment, at the rate agreed upon, 

for services actually rendered if I have been employed.

I agree that I will not accept employment by any client or former client or competitor of the Company, where I have

been employed by the Company, for a period of 120 days from the termination of my employment with the Company. 

I agree that I will not divulge to anyone, other than as I may be directed by the Company, any information acquired 

by me during my employment, except as may be required by law.

I understand that all appointments are probationary for 90 days, during which time I must demonstrate my ability 

for continued employment. I further certify that all statements made by me on this application are true and 

complete to the best of my knowledge and belief.

HOW DID YOU LEARN ABOUT VICTORY SECURITY AGENCY?  Walk-in   Advertisement   Friend 

Employment Agency   Relative   Internet   Yellow Pages   Employee  Name: