Employment Application

     All qualified applicants will receive consideration for employment without regard to race, color, creed, sex or national origin. This company offers equal opportunity and treatment to all employees and applicants. All information will be held in strictest confidence. This application will become a permanent part of your personnel record if you are employed.
 

Full Name:
Soc. Sec. No.:
Street and No.
City:
State:
Zip Code:
Years at Residence:
Telephone:
E-mail:
List address of residence for the last five years.
Street and No. City State Zip From Until

List any foreign languages that you speak fluently:


 
 
Education

 
Level School Name & Location Years Attended Date Graduated Title of Degree or Certificate Major & Minor Subjects
High School
College
Other

 
 
Employment
(Be accurate, detail your complete record of past employment. Begin with your current or most recent employment.)

 
Company Name & Location Specific Duties Immediate Superior Reason for Leaving Employed from (Date) Employed until (Date) Starting Pay per Month End Pay
per Month
May we contact your present employer?
Yes
No   If Not, Why?  
Do you have a valid Driver's License?
State & License #:
Have you had a valid Driver's License for 3 consecutive years?
Has your license ever been suspended or revoked in any state?
List approximate dates of revocation or suspension:
List any traffic violations for last 6 years (except parking). Approx. Date
Have you ever been convicted of any crime?
If so, in what state(s)?
Have you ever worked in this industry?
If so, for whom?
Do you have any relatives working for this company?

 
 
Personal Data

 
When are you available for employment?
Nearest living relative:
Name and location of a bank you presently use:
Have you ever been a member of the Armed Forces?

 
 
Insurance

 
List types and amounts of Life and Health Insurance you carry:

 
 
Physical and Medical Record

 
Weight:
Height:
Describe your present state of health:
Are you presently under a doctor's care?
If so, explain:
How many times in the last 5 years, and for what periods have you been unable to work because of illness?
Explain:
If we have a position in another area, would you be willing to relocate?
Area preferred:
Explain:

 
 
Additional Information

 
What particular assets in experience, personality, or ability do you have that qualifies you for a career with our company?
 
Applicant's Certification and Agreement
     I hereby authorize all my previous employers, or references to furnish any information concerning my personal character, habits or employment records. I hereby release all such persons from liability or damages incurred as a result of inquiry and furnishing this information.
 
     I hereby certify that all statements made in this application for employment are true and correct to the best of my knowledge and belief.

Date
Signature (Please type your name.)
 

 
 


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