APPLICATION FOR EMPLOYMENT

Prospective employees will receive consideration without

discrimination base on race, creed, color, sex, age, national origin,

 handicap, veteran status or any condition prescribed by state or local law.

Date:______________

PERSONAL

Name (Last, First, Middle):

Street Address:

Home Phone:                                       Cell Phone:                                           Social Security#:

Have you ever applied for employment with us?   Yes    No     If Yes, when:

Position Desired:                                                  FT    PT    PD          Hours Available:                                                Pay Expected:

Are you willing to work overtime?  Yes  No                    Are you legally eligible for employment in the US?    Yes    No

Date Available to Start:

Have you ever been convicted of any crimes in the past ten years, excluding misdemeanors and summary offenses, which have not been annulled, expunged or sealed by a court?      Yes                         No                                                                    If Yes please explain in full:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    

Other special training or skills (languages, machine operation, etc.)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         

EDUCATION

SCHOOL	NAME AND LOCATION OF SCHOOL	COURSE OF STUDY	NO. OF YEARS COMPLETED	DID YOU GRADUATE
GRADUATE				Y     N
COLLEGE				Y     N
BUSINESS/TRADE/ TECHNICAL				Y     N
HIGH SCHOOL				Y     N
ELEMENTARY				Y     N

EMPLOYMENT(Please give accurate, complete full time and part time employment record.  Start with your present or most recent employeer)

Company Name:                                                                                                                Telephone:

Address  :                                                                                                               Employed From:                 To:

Name of Supervisor:                                                                                           Weekly Pay Start:               Last:

State Job Title and description of your work:                                                                Reason for Leaving:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

May we contact?    Yes    No   If no, what is your reason?                                                                                                                         

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Company Name:                                                                                                                Telephone:

Address  :                                                                                                               Employed From:                 To:

Name of Supervisor:                                                                                           Weekly Pay Start:               Last:

State Job Title and description of your work:                                                                Reason for Leaving:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

May we contact?    Yes    No   If no, what is your reason?                                                                                                                         

Company Name:                                                                                                                Telephone:

Address  :                                                                                                               Employed From:                 To:

Name of Supervisor:                                                                                           Weekly Pay Start:               Last:

State Job Title and description of your work:                                                                Reason for Leaving:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

May we contact?    Yes    No   If no, what is your reason?                                                                                                                         

Company Name:                                                                                                                Telephone:

Address  :                                                                                                               Employed From:                 To:

Name of Supervisor:                                                                                           Weekly Pay Start:               Last:

State Job Title and description of your work:                                                                Reason for Leaving:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

May we contact?    Yes    No   If no, what is your reason?                                                                                                                         

MILITARY

Did you serve in the U.S. Armed Forces?    Yes     No                   If Yes, What Branch?

Describe any training received relevant to the position for which you are applying:

REFERENCES (Please proved 3 references not related to you whom you have known for more than 1 year)

Name:                                                                    Phone Number:                                                    Years Known:

Relationship:                                                                                                                                                       

Name:                                                                    Phone Number:                                                    Years Known:

Relationship:                                                                                                                                                       

Name:                                                                    Phone Number:                                                    Years Known:

Relationship:                                                                                                                                                       

By my signature I attest that to my knowledge the above application has been truthfully filled out.

Signature:_________________________________________________________

Date:____________________