SAMPLE JOB APPLICATION

1 I have no preference. Mon. Tues. Wed. Thurs. Fri. Sat. Sun. Yes No Yes No Yes NoPLEASE NOTE: It is important that you complete all parts of the APPLICATION . If your APPLICATION is incomplete or does not clearly show the experience and/or training required, your APPLICATION may not be accepted. If you have no information to enter in a section, please write and AddressJob TypeName (First, MI, Last)TelephoneIf under 18, please list ageSocial Security NumberIf Yes, please explain:Have you had any accidents during the past three years?How many?Alternate PhoneEmailMailing AddressCity, State, and Zip CodeHave you ever been employed by this organization in the past?

2 I certify that I am a citizen, permanent resident, or a foreign national with authorization to work in the United you ever been convicted of, or entered a plea of guilty, no contest, or had a withheld judgment to a felony?Days/hours available to workHow many hours can you work weekly? Full time job Part time job Full or Part timeAdditional InformationHave you had any moving violations during the past three years?Do you have a driver s license? Yes NoDriver s license numberHow many?Date available to beginSAMPLE JOB APPLICATIONI ssued in what state?I am seeking a:Can you work nights?

3 Page 1 of 4 Years CompletedMajorDegree or Diploma Yes No Yes NoMilitaryHigh SchoolLocation (mailing address)EducationCollege or Business/Trade SchoolSchoolHave you even been in the Armed Forces?Are you now a member of the National Guard?Date enteredDischarge dateSpecialtypage 2 of 4 Hrs/weekHrs/weekWork ExperiencePlease list ALL work experience beginning with your most recent job held. Attach additional sheets if numberName of last supervisorYour last job titleMay we contact this employer? Yes NoPhone numberYour last job titleReason for leaving (be specific)List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this for leaving (be specific)List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this we contact this employer?

4 Yes NoCompanyName of last supervisorCompanyFinal SalaryAddressStart DateStarting SalaryCity, State, and Zip CodeEnd DateCity, State, and Zip CodeStart DateEnd DateStarting SalaryFinal SalaryAddresspage 3 of 4 Hrs/weekReferencesPlease include name, phone number, and circumstances of your acquaintance. Exclude relatives and former certify that all answers and statements on this APPLICATION are true and complete to the best of my knowledge. I understand that, should this APPLICATION contain any false or misleading information, my APPLICATION may be rejected or my employment with this company last job titleReason for leaving (be specific)List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this of last we contact this employer?

5 Yes NoAddressStart DateStarting SalaryCity, State, and Zip CodeEnd DateFinal SalaryPhone Experience (continued)page 4 of 4