Application for Employment

Personal Information

First Name

Last Name

Address

Phone Number

If yes, please explain:

Employment Desired

Kind of work desired? Required

Full-Time

Part-Time

If you would be available for part-time work, please list the days of the week and hours you would be available:

What shifts are you available to work? Required

Any shift

1st shift

2nd shift

3rd shift

Position desired?

Salary desired?

Date available to start:

If so, when?

Who were you referred by?

General Information

Special Skills:

Rank:

If yes, please explain:

How much time have you lost from work or school during each of the past TWO calendar years FOR REASONS OTHER THAN VACATION AND HOLIDAYS:

Year

# of Days

Year

# of Days

Former Employers

(List below the last 3 employers, starting with the last one first)

Employer One:

Start Date:

End Date:

Name & Address of Employer:

Salary:

Position:

Reason for Leaving:

Employer Two:

Start Date:

End Date:

Name & Address of Employer:

Salary:

Position:

Reason for Leaving:

Employer Three:

Start Date:

End Date:

Name & Address of Employer:

Salary:

Position:

Reason for Leaving:

References

(Give the names of 3 persons not related to you, whom you have known at least one year)

Reference One:

Name:

Address

Phone Number

Years Acquainted:

Reference Two:

Name:

Phone Number

Address

Years Acquainted:

Reference Three:

Name:

Address

Phone Number

Years Acquainted:

Emergency Contact

In case of emergency, notify:

Name

Phone Number

Address

Thank you for applying!