Your interest in our organization is appreciated. we comply with state and federal laws regarding equal opportunity. Qualified applicants are considered for all positions without regard to race, color, religion, sex, age, disability, national origin, veteran status, or citizenship status.
POSITION APPLYING FOR: DATE:
Personal Information:
NAME (Last, First, Middle)
Social Security Number Telephone Number
Address
City StateZip Code
Have you ever been know by any other name? Yes No
If Yes, what is the name?Dates know by this name?
In case of emergency, who should be contacted?
Name:Relationship
Address:Phone:
Have you ever been convicted of a felony? Yes No
If yes, describe in full:
Are you a citizen of the United States? Yes No
If not, give Alien Registrations Number:
Are you over age 18? Yes No If no, do you have a work permit? Yes No
Referral Source: Advertisement Friend Relative
Employment Agency Other
Do any of your friends or relatives work here? Yes No
If yes, list name(s)
List office or business machines you have operated:
If applying for a clerical position:
What is your typing speed?
Do you take shorthand? Yes No ---- If so, what is you speed?
Give name, address, and phone number of three personal references whom you've known for at least five (5) years, not related to you:
1. Telephone
2. Telephone
3. Telephone
If required for the position for which you are applying, will you consent to periodic physical examinations and blood or urine analysis at company expense? (Note: This analysis may test for controlled substances) Yes No
Have you filed an application here before? Yes No Date:
Have you ever been employed here before? Yes No Date:
Status desired: Full timePart time Other
If other, what Date available
If there are any hours you are unwilling to work, what are they and why?
Are you on lay-off and subject to recall? Yes No
Can you travel if a job requires it? Yes No
List any skills, qualifications, courses, or training you have that relate to the position for which you are applying.
Are you a member of the Military Reserve or National Guard? Yes No
Are you a member of the U.S. Military Service? Yes No
If yes what branch of the U.S. Military Service?
List Professional, Trade, Business or Civic activities and offices held:
(Exclude groups which indicate race, color, religion, sex or national origin)
Present and Past Employment, beginning with your most recent:
1. Name and Address of Company
Type of Business Employed: From: To:
Salary: Starting Ending
Describe the work you did:
Reason for Leaving
Name of Supervisor Telephone:
2. Name and Address of Company
3. Name and Address of Company
4. Name and Address of Company
May we contact the employers listed above? Yes No
If not, indicate which one(s) you do not wish us to contact and state the reason why not:
Have you ever been bonded? Yes No If yes, where?
Summarize special skills and qualifications acquired from employment or other experience:
Driving Record
Do you presently have a valid driver's license? YesNo
If yes, list the following driver's license information:
State Number Type Expiration Date
Have you had a moving violation within the past 5 years? Yes No
If yes, describe in detail:
Education:
High School Address
Course of Study
Check last ;year completed: 1234
Did you graduate: Yes No List diploma or Degree
Technical SchoolAddress
Check last year completed: 1234
Did you graduate? Yes No List diploma or Degree
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