| 1. PERSONAL INFORMATION | |||||||||
| Date: | |||||||||
| SS #: | |||||||||
| Name | |||||||||
| Last | First | Middle | |||||||
| Present Address | |||||||||
| Street | City | State | Zip | ||||||
| Permanent Address | |||||||||
| Street | City | State | Zip | ||||||
| Daytime | Home Tel. | ||||||||
| Tel. No. | if Different | Are you 18 years or older? | ___Yes | ___No | |||||
| 2. SPECIAL QUESTIONS | |||||||||
| DO NOT ANSWER ANY QUESTIONS IN THIS FRAMED AREA UNLESS THE EMPLOYER HAS | |||||||||
| CHECKED A BOX PRECEDING A QUESTION THEREBY INDICATING THAT THE INFORMATION IS | |||||||||
| REQUIRED FOR A BONA FIDE OCCUPATIONAL QUALIFICATION OR DICTATED BY NATIONAL | |||||||||
| SECURITY LAWS OR IS NEEDED FOR OTHER LEGALLY PERMISSABLE REASONS. | |||||||||
| q | Are you prevented from lawfully becoming | employed in the U.S? ____Yes | ____No | ||||||
| q | Date of Birth * ________________________ | ||||||||
| q | What foreign languages do you speak fluently? | ||||||||
| Read | Write | ||||||||
| q | Have you been convicted of a felony or misdemeanor within the last 5 years?** ___Yes ___No | ||||||||
| If yes, describe:_______________________________________________________________ | |||||||||
| ____________________________________________________________________________ | |||||||||
| * The Age Discrimination in employment Act of 1967 prohibits discrimination on the basis of age with respect to | |||||||||
| individuals who are at least 40 but less than 70 years of age. | |||||||||
| ** You will not be denied consideration for employment solely because of a conviction record unless the offense | |||||||||
| is related to the job for which you have applied. | |||||||||
| 3. EMPLOYMENT DESIRED | |||||||||
| Position | Date You Can Start | Salary Desired | |||||||
| Are you | If so, may we inquire | Ever applied to this | |||||||
| employed now? | of your present empoyer? | company before? | When? | ||||||
| _____________ | ___________________ | _______________ | _______________ | ||||||
PAGE 2
| Availability for Work | ________ | Full time | ________ | Part time | ________ | Temporary | ||
| Hours Available | to | Days | ||||||
| How did you hear about this position? | ||||||||
| 4. EDUCATION | ||||||||
| No. Years | Did you | Subjects | ||||||
| Name and Location of School | Attended | Graduate? | Studied | |||||
| High School ________________________________ | _____ | _____ | ||||||
| College ________________________________ | _____ | _____ | ||||||
| Trade or | ||||||||
| Business | ||||||||
| School _________________________________ | _____ | _____ | ||||||
| 5. GENERAL, U.S. MILITARY OR NAVAL SERVICE | Rank ___________________ | |||||||
| Present membership in National Guard or Reserves _____________________ | ||||||||
| Please indicate any special skills and or qualifications you possess that you feel relate directly to | ||||||||
| the position for which you are applying. Typing, special licenses or certifications, computer | ||||||||
| knoledge, machine skills, etc. | ||||||||
| 6. FORMER EMPLOYERS | List below your last four employers starting with the last one first. | |||||||
| Date | Name/Address | Salary | ||||||
| Mo/Year | of Employer | Position | Responsibilities | Reason for Leaving | ||||
| From | ||||||||
| To | ||||||||
| From | ||||||||
| To | ||||||||
| From | ||||||||
| To | ||||||||
| From | ||||||||
| To | ||||||||
PAGE 3
| 7. REFERENCES | Provide names of three persons not related to you whom you have known | |||||||
| at least one year. | ||||||||
| Name | Address | Business | Years Acquainted | |||||
| 1 | ||||||||
| 2 | ||||||||
| 3 | ||||||||
| 8. PHYSICAL RECORD | ||||||||
| Do you have any physical limitations that prevent you from performing any work for which you are | ||||||||
| being considered? _____ Yes _____ No | ||||||||
| If Yes, what can be done to accommodate your limitation? | ||||||||
| Please Describe: | ||||||||
| In case of emergency, notify: | ||||||||
| Name | Address | Phone | Relationship | |||||
| 9. OTHER COMMENTS | ||||||||
| Prospective employees will receive consideration without discrimination because of Race, | ||||||||
| Creed, Color, Sex, Age, National Origin or Handicap. Completion of this application does not imply | ||||||||
| or warrant that the applicant will be considered for a positon in the Company. | ||||||||
| I certify that the facts contained in this application are true and complete to the best of my | ||||||||
| knowledge and understand that, if employed, falsified statements on this application shall be | ||||||||
| grounds for dismissal. | ||||||||
| I authorize investigation of all statements contained herein and the references listed above to give | ||||||||
| you any and all information concerning my previous employment and any pertinent information | ||||||||
| they may have personal or otherwise and release all parties from all liability for any damage that | ||||||||
| may result from furnishing same to you. I understand and agree that, if hired, my employment is | ||||||||
| for no definite period and may, regardless of the date of payment of my wages and salary, be | ||||||||
| terminated at any time without prior notice. | ||||||||
| DATE __________________ | SIGNATURE ___________________________________________ | |||||||