Position(s) applied for

Date of Application

How did you learn about us?

______ Advertisement                ______ Friend            _____ Walk-in

______Employment Agency      ______ Relative          _____ Other _______________

Last Name                                       First Name                                     Middle Name

Address       Number               Street                   City                 State             Zip Code

Telephone Number(s)

Social Security Number

             -         -

1

Employer

Date Employed

Work Performed

From

To

Address

Telephone Number(s)

Hourly Rate/Salary

Starting

Final

Job Title                 Supervisor

Reason for Leaving

2

Employer

Date Employed

Work Performed

From

To

Address

Telephone Number(s)

Hourly Rate/Salary

Starting

Final

Job Title                 Supervisor

Reason for Leaving

3

Employer

Date Employed

Work Performed

From

To

Address

Telephone Number(s)

Hourly Rate/Salary

Starting

Final

Job Title                 Supervisor

Reason for Leaving

4

Employer

Date Employed

Work Performed

From

To

Address

Telephone Number(s)

Hourly Rate/Salary

Starting

Final

Job Title                 Supervisor

Reason for Leaving

Elementary School

High School

Undergraduate

College/University

Graduate

Professional

School Name and Location

Years Completed

4     5     6     7     8

9     10     11     12

1       2       3       4

1         2        3       4

Diploma/Degree

Describe Course of Study

Describe any specialized training, apprenticeship skills and extra curricular

activities

Describe any honors

you have received

State any additional

information you feel

may be helpful to us

in considering your

application

Indicate any foreign languages you can speak, read and/or write

Fluent

Good

Fair

Speak

Read

Write

List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status:

Give name, address and telephone number of three references that are not related to you and not previous employers.

1. _______________________________________________________________________________________________________

2. ______________________________________________________________________________________________________

3. ______________________________________________________________________________________________________

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

              ____________________________________                                            _______________________

                          Signature of Applicant                                                                                Date

FOR PERSONNEL DEPARTMENT USE ONLY

Arrange Interview      _____ Yes     _____ No

Remarks ______________________________________________________________________________________

                  ______________________________________________________________________________________

                  ______________________________________________________________________________________

Employed    _____Yes     _____No                                 Date of Employment _____________________________

Job Title _________________________ Salary/Hourly Rate________ Department ______________________

                             BY______________________________________________________________________________

                                                                                     Name and Title                                            Date