Personal Information

Are you a U.S. citizen?

YesNo

If No, are you legally allowed to work in the U.S.?

YesNo

Registration number

Date (month, day, year)

Social Security number (Please enter last four (4) digits only)

Name (last, first, middle)

Present address (number and street, city, state, and ZIP code)

Permanent address (number and street, city, state, and ZIP code)

Primary telephone number

Alternate telephone number

Have you ever been convicted of a felony?

YesNo

If Yes, explain in full.

Do you have a valid driver's license?

YesNo

If Yes, what type?

OperatorCommercialChauffeur

Employment Desired

Position for which you are applying

Date you can start (month, day, year)

Are you currently employed?

YesNo

If so, may we contact your present employer?

YesNo

Have you ever applied to this company before?

YesNo

Work preference

Education

Elementary/Middle School

Name and Location of School

Last Year Completed

Did you graduate?

YesNo

Subjects studied and certificate, diploma, degree received

High School

Name and Location of School

Last Year Completed

Did you graduate?

YesNo

Subjects studied and certificate, diploma, degree received

College

Name and Location of School

Last Year Completed

Did you graduate?

YesNo

Subjects studied and certificate, diploma, degree received

Trade, Business, or Correspondence School

Name and Location of School

Last Year Completed

Did you graduate?

YesNo

Subjects studied and certificate, diploma, degree received

Describe any special studies, skills, and experiences, or foreign language abilities that could enhance your job performance.

Physical Record

Do you have any physical condition which may limit your ability to perform the job for which you are applying? This question is voluntary, and any answers will be kept confidential.

Employment History

List your last four employers starting with the most recent

Employer 1

Name of employer and address:

Position title, duties, and skills:

Start date (mm/dd/yyyy)

End date (mm/dd/yyyy)

Pay (add per hour/year/etc)

Name of supervisor

Telephone number

Reason for leaving:

Employer 2

Name of employer and address:

Position title, duties, and skills:

Start date (mm/dd/yyyy)

End date (mm/dd/yyyy)

Pay (add per hour/year/etc)

Name of supervisor

Telephone number

Reason for leaving:

Employer 3

Name of employer and address:

Position title, duties, and skills:

Start date (mm/dd/yyyy)

End date (mm/dd/yyyy)

Pay (add per hour/year/etc)

Name of supervisor

Telephone number

Reason for leaving:

Employer 4

Name of employer and address:

Position title, duties, and skills:

Start date (mm/dd/yyyy)

End date (mm/dd/yyyy)

Pay (add per hour/year/etc)

Name of supervisor

Telephone number

Reason for leaving:

Military Service

Branch of service

Active duty start date (mm/dd/yyyy)

Active duty end date (mm/dd/yyyy)

Rank at discharge

Describe duties / specialized training.

Organizations and Volunteer Activities

List responsibilities and offices.

References

Give below the names of three persons not related to you, whom you have known for at least one year.

Person 1

Name

Address

Telephone Number

Business

Years Acquainted

Person 2

Name

Address

Telephone Number

Business

Years Acquainted

Person 3

Name

Address

Telephone Number

Business

Years Acquainted

Signature

I authorize investigation of all statements contained in this application. I understand that misrepresentation of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at anytime without any previous notice.

Signature

Date (month, day, year)