employment application
Please complete this form to apply for a job.  Use TAB to advance from section to section; do not use ENTER.  
Please see instructions that follow form to send it to us.

personal information

Name: Today's Date:

Present Address:

City: State: Zip Code: Phone No:

Are you 18 years or older? Yes No

employment desired

Position: Date you can start: Salary Desired: $/hr

education
If you studied any related work, please note.

High School: Years Attended: Graduate? Yes No
Related Work:

Trade School: Years Attended: Graduate? Yes No
Related Work:

College: Years Attended: Graduate? Yes No
Related Work:

former employers
List last four employers, starting with the most recent first.

1.Name fromto

salary: $/hr position: left why?

2.Name fromto

salary: $/hr position: left why?

3.Name fromto

salary: $/hr position: left why?

4.Name fromto

salary: $/hr position: left why?

references
Give names of three persons not related to you whom you have know at least one year.

1. Name Phone
2. Name Phone
3. Name Phone

other
Please list any other pertinent information below.

physical record
Do you have any physical limitations that preclude you from performing any work for 
which you are being considered? If so, please describe below:

In case of emergency, notify: Phone:

legal paragraph
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be ground for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.

Signed Date: .