personal Information

Name___________________________________________________________________________________     

Present Address__________________________________________________________________________

Telephone Number(s)  (________) _________________________________________________________

Job(s) applied for 1. _______________________________    Rate of pay expected $__________/per hour
                                2. _______________________________    Rate of pay expected $__________/per hour

How did you learn of this opening? ____________________________________________

Do you want to work   ____Full-Time or   ___Part-Time. Specify days and hours if part-time ________________________________________________________________________

________________________________________________________________________

If hired, on what date will you be able to start work? ________________________________________________________________________

Are there any other experiences, skills or qualifications which you feel would especially fit you for work with us?
(If necessary, additional space is provided to complete this section on page 3 under Personal References.)
Please exclude activities which would indicate any prohibited grounds of discrimination listed above._________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

If hired, do you have reliable means of transportation to get to work? _______________

Describe any specialized training, apprenticeship skills and extra-curricular activities: ________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Dates Worked   from: _________________________ to: _______________________________
Name and Address of Employer: ____________________________________________________
_________________________________________________________________________________
Rate of Pay       start: ________________________  end: _______________________________
Supervisor Name and Title: ________________________________________________________
Reason for Leaving: _______________________________________________________________
Describe the work you did: ________________________________________________________

Dates Worked   from: _________________________ to: _______________________________
Name and Address of Employer: ____________________________________________________
_________________________________________________________________________________
Rate of Pay       start: ________________________  end: _______________________________
Supervisor Name and Title: ________________________________________________________
Reason for Leaving: _______________________________________________________________
Describe the work you did: ________________________________________________________

Dates Worked   from: _________________________ to: _______________________________
Name and Address of Employer: ____________________________________________________
_________________________________________________________________________________
Rate of Pay       start: ________________________  end: _______________________________
Supervisor Name and Title: ________________________________________________________
Reason for Leaving: _______________________________________________________________
Describe the work you did: ________________________________________________________

May we contact the employers listed above? ________ If not, indicate below which one(s) 
you do not wish us to contact._______________________________________________________

Give the names of at least 3 persons who can supply information pertinent to your job performance
(excluding former employers or relatives)

1. Name and Occupation: __________________________________________________________________________
   Address: _______________________________________________________________________________________
   Phone Number(s): ______________________________________________________________________________
2. Name and Occupation: __________________________________________________________________________
   Address: _______________________________________________________________________________________
   Phone Number(s): _______________________________________________________________________________
3. Name and Occupation: ___________________________________________________________________________
   Address: _______________________________________________________________________________________
   Phone Number(s): ______________________________________________________________________________
4. Name and Occupation: ___________________________________________________________________________
   Address: ________________________________________________________________________________________
   Phone Number(s): _______________________________________________________________________________

To assist us in finding the proper position for you in our company, use the space below to summarize any additional information necessary to describe your full qualifications.

Thank you for completing this application form and for your interest in employment with us. We would like to assure you that your opportunity for employment with this company will be based only on your merit and on no other consideration.

please read carefully

applicant's certification and agreement

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements on this application shall be considered sufficient cause for dismissal.

Signature of Applicant: __________________________________________________________________