: Employment Application

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Employment Application

EMPLOYEE DATA

First Name

Last Name

Middle Initial

Email Address

Current Address

City

State

Postal Code

Phone

How long have you been at this address?

Prior address if less than 1 year.

Prior City

Prior State

Prior Postal Code

page 1 of 7

Have you worked for this company before?

Yes

No

If so, when?

Names of friends or relatives who currently work for this company:

page 2 of 7

EMERGENCY CONTACT INFORMATION

Name

Home Phone

Work Phone

Address

City

State

Postal Code

Name

Home Phone

Work Phone

Address

City

State

Postal Code

page 3 of 7

POSITION DESIRED

Position:

Sales Manager

Service Center Manager

Lead Technician

Floor Technician

Independent Contractor

When you can start:

Are you currently employed?

Yes

No

If so, may we contact your current employer?

Yes

No

page 4 of 7

EMPLOYMENT HISTORY

List your past three (3) employers, beginning with the most recent.

Employer #1

Company

Address

Phone

Supervisor

Start Month

Start Year

End Month

End Year

Reason for Leaving

Duties

Employer #2

Company

Address

Phone

Supervisor

Start Month

Start Year

End Month

End Year

Reason for Leaving

Duties

Employer #3

Company

Address

Phone

Supervisor

Start Month

Start Year

End Month

End Year

Reason for Leaving

Duties

page 5 of 7

EDUCATIONAL BACKGROUND

List the past three (3) schools you attended, beginning with the most recent.

#1 School Name and Address

Years Completed

Did you Graduate?

check if Yes

Major / Degree

#2 School Name and Address

Years Completed

Did you Graduate?

check if Yes

Major / Degree

#3 School Name and Address

Years Completed

Did you Graduate?

check if Yes

Major / Degree

List any foreign languages you can speak and choose your level of fluency.

Language

Level of Fluency

Language

Level of Fluency

Language

Level of Fluency

Language

Level of Fluency

List any special skills/abilities you have that can be applied to this position.

page 6 of 7

SECURITY

Have you ever been bonded?

No

Yes

If so, explain.

Have you been convicted of a felony within the past 5 years?

No

Yes

If so, explain. (this will not necessarily exclude you from consideration).

Are you legally able to work in the United States?

No

Yes

MILITARY

Have you served in the military?

No

Yes

Branch

Served From:

Served To:

Rank

Do you have any military committment, including National Guard service that would influence your work schedule?

No

Yes

If so, explain.

Are you a Vietnam Veteran?

No

Yes

Are you a disabled Veteran?

No

Yes

Are you a special disabled Veteran?

No

Yes

REASONABLE ACCOMMODATIONS: In the event you believe you will need reasonable accommodations to assist you in performing your job, please contact your supervisor or human resources coordinator.

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