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WE ARE AN EQUAL OPPORTUNITY EMPLOYMENT COMPANY. WE ARE DEDICATED TO A POLICY OF NON DISCRIMINATION IN EMPLOYMENT ON ANY BASIS INCLUDING RACE, CREED, COLOR, AGE, SEX, RELIGION, OR NATIONAL ORIGIN OR PHYSICAL HANDICAP. 

(PLEASE PRINT)
PERSONAL INFORMATION
DATE
NAME
  LAST FIRST MIDDLE
PRESENT ADDRESS
  STREET CITY STATE ZIP
PERMANENT ADDRESS
  STREET CITY STATE ZIP
PHONE NO. SOCIAL SECURITY NUMBER
REFERED BY:

EMPLOYMENT DESIRED
POSITION DATE YOU

CAN START SALARY

DESIRED
ARE YOU EMPLOYED NOW? IF SO, MAY WE INQUIRE

OF YOUR PRESENT EMPLOYER?
EVER APPLIED TO THIS COMPANY BEFORE? YES NO DATE

EDUCATION NAME AND LOCATION OF SCHOOL YEARS ATTENDED GRADUATED SUBJECT STUDIED
GRAMMAR SCHOOL

HIGH SCHOOL

COLLEGE

TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL

SUBJECT OF SPECIAL STUDY OR RESEARCH WORK

U.S. MILITARY OR

NAVAL SERVICE RANK PRESENT MEMBERSHIP IN

NATIONAL GUARD OR RESERVES
ACTIVITIES OTHER THAN RELIGIOUS

(CIVIC, ATHLETIC, FRATERNAL, ETC)
EXCLUDE ORGANIZATIONS, THE NAME OR CHARACTER OF WHICH INDICATES THE RACE, CREED, COLOR, OR NATIONAL ORIGIN OF IT’S MEMBERS. (CONTINUED ON OTHER SIDE)


FORMER EMPLOYERS: (LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)
DATE

MONTH AND YEAR NAME AND ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING
FROM
TO
FROM
TO
FROM
TO
FROM
TO
REFERENCES: (GIVE BELOW THE NAMES OF TWO PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR)
NAME ADDRESS BUSINESS YEARS ACQUAINTED

 I hereby authorize and request any and all of my former employers and any other person, firm, or corporation to furnish any and all information concerning my credit-worthiness and personal background and I hereby release each such employer or other person, firm, or corporation from any and all liability by reason of furnishing the requested information. I understand that in connection with this application, a consumer report and/or an investigative consumer report may be requested whereby information is obtained through personal interviews with my neighbors, friends, or associates or with others with whom I am acquainted or who my have knowledge with respect to my character, general reputation, personal characteristics and mode of living, and hereby authorize the procurement of any such report. I understand that, upon my request, I have the right to know if any such report was requested an, if so, the name and address of the consumer reporting agency that furnished such report and in the case of a consumer investigative report, that I may inspect and receive a copy of such report by contacting such agency. I also understand that I have the right to receive a complete and accurate disclosure of the nature and scope of the information requested if I request such disclosure within a reasonable period of time.
 

I understand that if employed: 1) any misrepresentation or omission of facts requested in this application is cause for dismissal; and 2) my employment is for no definite period and I may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.



 
DATE: SIGNATURE OF APPLICANT: 

 
FOR OFFICE USE ONLY
INTERVIEWED BY DATE REMARKS
NEATNESS CHARACTER
PERSONALITY ABILITY
HIRED FOR DEPT. POSITION WILL REPORT SALARY

WAGES
APPROVED 1. 2. 3.
EMPLOYMENT MANAGER DEPT. HEAD GENERAL MANAGER
IN CASE OF

EMERGENCY NOTIFY
NAME ADDRESS PHONE NO. 


 
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