Employment Form
Last Name: _______________________
First: _________________ MI: ___
Date of Application: _________________
Street Address: ______________________________________
City:_________________State:_________ZIP:____________
Type(s) of Work Desired:
_____________________________________________________
Social Security number:______________________________
Home telephone: _________________
Work telephone: _________________
How Were You Referred To Us? (Circle only one.)
A By Your College
B Advertisement
C Employment Agency
D By an Employee
If So, Give Name: ________________________________
E Open house
F Walk-in
G Other
Please Read Carefully And Complete By Printing In Ink Or Typing.
An Equal Opportunity Employer
We are an equal opportunity employer, and we do not and will not
discriminate on the basis of race, religion, national origin, sex, age,
handicap, marital status, or status as a disabled veteran. Information
provided on this application will not be used for any discriminatory
purpose.
Provide All Information Requested.
Your complete application form will be maintained in our active files for
six (6) months from the date of application. You may submit a new
application at any time.
EMPLOYMENT RECORD
Starting with present or most recent, list all previous employers. Include
self-employment and summer and part-time jobs. If more space is required,
please continue on a separate sheet. You may attach a resume, but complete
this application as well.
Last Or Present Company:
____________________________________________________________________
Type of Business:
____________________________________________________________________
Type or Classification of Job:
____________________________________________________________________
Street Address:______________________________________
City:_________________State:_________ZIP:____________
Phone number:_________________
Brief Description of Job Duties:
____________________________________________________________________
Supervisor's Name:__________________________________
Phone number:_________________
Base salary:__________________
Dates worked: From___________ To____________
Reason for leaving:
____________________________________________________________________
Last or Present Company:
___________________________________________________
Type of Business:
___________________________________________________
Type or Classification of Job:
___________________________________________________
Street Address:______________________________________
City:_________________ State:_______ ZIP:____________
Phone number:_________________
Brief Description of Job Duties:
___________________________________________________
Supervisor's Name:
___________________________________________________
Phone number:_________________
Base salary:_________________
Dates worked: From _____________ To _______________
Reason for Leaving:
___________________________________________________
EDUCATIONAL HISTORY
High School:
School Name: _____________________________________________
Location (city, state): __________________________________
Major Course or Subject:__________________________________
Dates Attended: From _____________ To _______________
Graduated: Yes ____________ No ___________
Degree: __________________________________
Technical/Trade (after high school)
School Name: _____________________________________________
Location (city, state): __________________________________
Major Course or Subject:__________________________________
Dates Attended: From _____________ To _______________
Graduated: Yes ____________ No ___________
Degree: __________________________________
College (list all attended)
School Name: _____________________________________________
Location (city, state): __________________________________
Major Course or Subject:__________________________________
Dates Attended: From _____________ To _______________
Graduated: Yes ____________ No ___________
Degree: __________________________________
School Name: _____________________________________________
Location (city, state): __________________________________
Major Course or Subject:__________________________________
Dates Attended: From _____________ To _______________
Graduated: Yes ____________ No ___________
Degree: __________________________________
Other education/training
School Name: _____________________________________________
Location (city, state): __________________________________
Major Course or Subject:__________________________________
Dates Attended: From _____________ To _______________
Graduated: Yes ____________ No ___________
Degree: __________________________________
School name: _____________________________________________
Location (city, state): __________________________________
Major Course or Subject:__________________________________
Dates Attended: From _____________ To _______________
Graduated: Yes ____________ No ___________
Degree: __________________________________
OUTSIDE ACTIVITIES
(Exclude those indicating race, color, religion, sex, national origin, age,
or handicap.) Professional memberships, certificates, or licenses held
___________________________________________________
___________________________________________________
___________________________________________________
Past and Present Civic or Cultural Activities (include offices held)
___________________________________________________
___________________________________________________
Principal Hobbies
___________________________________________________
___________________________________________________
SPECIAL SKILLS
To be Completed by Applicant for Office/Clerical Work
Typing: Yes____ Words per Minute: _________ No____
Dictation: Yes____ Words per minute: _________ No____
To be Completed By Applicant for Shop/Plant Work
Type of Machines Operated:
___________________________________________________
___________________________________________________
Years Experience: ________
Computer Skills
Hardware:
___________________________________________________
Software:
___________________________________________________
Please list Other Skills and/or Equipment/Language Experience You Have
Acquired:
___________________________________________________
___________________________________________________
List Other Shop/Production Skills:
___________________________________________________
___________________________________________________
Served Apprenticeship:
Yes_______ Type: __________________________________
No_______
MILITARY RECORD
Branch of Service
___________________________________________________
From _____________ To ____________
Present Military Affiliation:
None____ Reserve (active)_____ Reserve (inactive)______
Kinds of Training and Duty While in Service:
___________________________________________________
___________________________________________________
PROFESSIONAL/WORK REFERENCES
List two past supervisors and one person who is not related to you who have
knowledge of your qualifications for the position for which you are
applying.
Name: ___________________________________________________
Title/Relationship: _____________________________________
Street Address:______________________________________
City:_________________State:_________ZIP:____________
Phone no. (include area code)______________________
Occupation: _______________________________________
May We Contact Your Present Employer?
Yes ________ No _________
Wage or Salary Required: _________________
Date Available: _________________
I hereby certify that the answers and other information on this application
are true and correct and that I understand any misrepresentation or
omission of facts on my part will be justification for separation from the
company's service, if employed. I understand that my employment may be
contingent upon receipt of an alien registration number, verification of
birth, and any other pertinent information bearing upon my employment, and
that my continued employment depends upon the will of the company or
myself.
___________________________________________________
Signature
Date: _________________
If any of your educational or employment records are under other than the
above name, please provide other names.
___________________________________________________
___________________________________________________
