Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race, color, national origin, religion, age, sex, disability, or any other factor prohibted by law or regulation.

AN EQUAL OPPORTUNITY EMPLOYER

Please fully and accurately complete each question. Incomplete applications may not be considered.

 

Referred by:

 

PERSONAL IDENTIFICATION

Last

First

Middle
 

Date:
Address:

Street

City

State

Zip

 

Phone:

 

WORK PREFERENCE

Position desired:
Salary or pay you expect:
Date available for work:
 

List job benefits, other than wages, you expect or want in order of importance:

Most Important

2nd Most Important

3rd Most Important
 

Describe your prior experience related to this work:
List any licenses, certificates, or professional affiliations you may have:
List any special skills you may have (computer, machine operation, etc.):
List any hobbies, special interests or sports in which you are involved:

 

Do you have a valid driver’s license?

Driver’s license number:
Class of license:
State:
Have you had your driver’s license suspended or revoked in the last three years?

If yes, give details:

 

AVAILABILITY FOR WORK

Part time:

Full time:

Temporary or short term:

 
Day:

Afternoon:

Graveyard:

Rotating:

 

Will you work daily overtime on occasion if necessary?

Will you work extra days in the week if necessary?

Are you now or do you expect to be engage in any other business, employment or schooling?

Do you have any commitments or agreements with another employer that might affect your employment?

Do you have any on-going obligations or other personal commitments that would affect your work schedule?

 

PRESENT EMPLOYMENT

Are you presently employed?

Do you have to give advance notice to your present employer?

May we contact your present employer for a reference?

 

PERSONAL

If requested, would you be willing to take a drug/alcohol screening exam before and/or after employment as a condition of employment?

Are you at least 18 years old?

If hired, can you furnish proof that you are eligible to work in the U.S.?

 

PRIOR EVENTS

Have you ever worked for or applied for work at this company before?

Have you ever been discharged for a cause?

Have you ever been refused a surety bond or ever had one cancelled?

Have you ever been convicted of any law violation, except a minor traffic violation? (A criminal record does not automatically bar employment)

Have you ever been disciplined for absenteeism?

Have you ever been disciplined for tardiness?

Explanation to answers given above:

 

EDUCATION AND TRAINING

Highest grade completed:

College or other:

  School Name & Location Dates Attended Received Diploma GPA Major Subjects / Special Courses
From To
High School or GED
College or University
Graduate School
Other Education
 

EMPLOYMENT RECORD

Give a complete account of your employment. BEGIN WITH YOUR PRESENT OR MOST RECENT POSITION AND WORK BACK.



Most recent employer

Employer:
Address:
Phone:
 

Main Duties:

From:
To:
 
Starting pay:
Leaving pay:
 

Supervisor:

What did you like about this job?
What did you dislike about this job?
Reason for leaving:
 

Previous employer 2

Employer:
Address:
Phone:
 

Main Duties:

From:
To:
 
Starting pay:
Leaving pay:
 

Supervisor:

What did you like about this job?
What did you dislike about this job?
Reason for leaving:
 

Previous employer 3

Employer:
Address:
Phone:
 

Main Duties:

From:
To:
 
Starting pay:
Leaving pay:
 

Supervisor:

What did you like about this job?
What did you dislike about this job?
Reason for leaving:
 

 

APPLICANT AGREEMENT

(Read carefully before signing.)

All information provided by me is true and correct to the best of my knowledge. I understand omissions or misrepresentations may result in rejection of my application or, if employed, may result in subsequent dismissal. I hereby authorize any former employer, person, school, firm or corporation listed hereon, including this company, to answer any and all questions related to employment and agree to release from liability and hold all persons harmless for giving any and all truthful information within their knowledge or records. I understand this is a preliminary application and not a contract to employ me. Furthermore, in the event I am employed, my employment shall be completely voluntary and may be terminated at will at any time by either myself or the company. I understand no one other than the company president has authority to enter into any employment agreement to the contrary. I agree a to take a job-related physical examination or drug/alcohol test when requested as a condition of employment. I agree to comply with all the rules of the company as a condition of employment.

Date:
Type your full name to sign: