Who should be contacted in case of emergency?
Name:
Phone:
Address:

Position applied for:
Wage desired:
Have you applied here before? yes no
Date available to start:

If you applied or worked for us before state when and where:

How did you learn of our company or position?

Are you now or do you expect to be involved in any other business or employment? yes no

Are there any days when you would be unable or unwilling to work? yes no

Can you lift a minimum of 70 lbs.? Yes No

Can you perform all specific tasks associated with the position you are applying for without special apparatus or with minimal changes or alterations to the company? Yes No

Have you used any illegal drugs, including marijuana, in the last twelve months? Yes No

Do you smoke or use tobacco products Yes No

Have you ever been convicted of a crime (excluding minor traffic violations), including DUI?
Yes No ......If yes, explain?
* If hired, non-disclosure/falsification of this section may lead to dismissal

Are you willing to take a drug screen, at our expense? Yes No

How many days leave did you take last year?

How many Fridays & Mondays did you take as leave last year?

High School: Graduate: Yes No
Courses Studied:
College: Graduate: Yes No
Courses Studied:
Trade School: Graduate: Yes No
Courses Studied:
 

In the space provided please list you strengths and weaknesses:

Are you planning to pursue further studies? Yes No
If so, when and what courses:

List any scholastic honors, offices held and activities involved during high school or college:

List and describe any other School or Specialized Training:

List names of employers in consecutive order with present or last employer listed first.
Account for all periods of time including military service and any periods of unemployment.
If self-employed, give the firm name and supply business references. Please give month and year.

Name of employer #1
Address:
Phone:
Name and title of last supervisor:
Starting Date of employment: Month Year Salary $
Ending Date: Month Year Salary $
Title:
Reason for leaving:

Duties:

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Name of employer #2
Address:
Phone:
Name and title of last supervisor:
Starting Date of employment: Month Year Salary $
Ending Date: Month Year Salary $
Title:
Reason for leaving:

Duties:

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Name of employer #3
Address:
Phone:
Name and title of last supervisor:
Starting Date of employment: Month Year Salary $
Ending Date: Month Year Salary $
Title:
Reason for leaving:

Duties:

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Have you ever worked under another name, please give that name:

Are you presently employed? Yes No
If yes, may we contact your present employer? Yes No

Special Skills
Do you type? Yes No .........if yes, words per minute
Have you had any computer or word processing experience or training? Yes No
If yes, please describe the extent:

What languages do you speak and or write fluently?

Use the space below to describe why you are interested in working for us. List the skills and abilities which you feel particularly qualify you for the position with us.


References
Give three references, not relatives or former employers. Please give name, address, phone, and occupation.

Affidavit

I certify that the answers given by me to the foregoing questions and statements are true and correct without any intentional omissions of consequence of any kind whatsoever. I understand that any misleading or incorrect statements may render this application void and, if employed, would be cause for termination. I further agree that you shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this questionnaire. I also authorize the companies, schools, or persons named above to give any information regarding my employment, character and qualifications and hereby release said companies, school, or persons from all liability for any damage for issuing this information. I certify that all statements and answers to questions about my abilities are true and were made without reservations. Further I agree to expressly waive all provisions of law prohibiting any physician, person, hospital or other institution from disclosing to us any information regarding treatment rendered now and in the future. I further understand that the taking of a drug test and physical are a condition of employment and refusal to take such tests when requested will subject me to termination. I also understand that no person is authorized to enter into any written or verbal employment contract on behalf of us without the express written consent of the company President. I understand my employment is at will.

Signature (type name):
Date:

Please select "Submit" to email it to us, or fax to (256) 536-6053