Name (First, Middle, Last):

Have you ever worked under another name? If Yes, what name:

What position are you applying for?

When are you available?

Phone Number:    E-Mail:

Salary or wages expected:

Present address:

     Street (include apt. no., if any)

     City   

     State 

     Zip    

Period of residence?

Previous address, if less than 12 months:

     Street (include apt. no., if any)

     City   

     State 

     Zip    

 Period of residence?

PROFESSIONAL REFERENCES

List three (3) professional references:

(1)    Name 

        Occupation 

        Address 

        Phone Number 

(2)    Name 

        Occupation 

        Address 

        Phone Number 

(3)    Name 

        Occupation 

        Address 

        Phone Number 

U.S. MILITARY SERVICE

Veteran of U.S. Armed Forces? Yes    No

If Yes:

Branch: 

Serial Number:

Highest Rank:

Major Duties:

Service schools and other special training: 

EDUCATIONAL DATA

COLLEGE

Name and Address of Institution: 

Dates: From to

Graduated:    Yes No

Degree Received:     Average Grades: 

Areas of Specialization: 

GRADUATE SCHOOL

Name and Address of Institution: 

Dates: From to

Graduated: Yes No

Degree Received:     Average Grades: 

Areas of Specialization: 

TRADE, BUSINESS, NIGHT or CORRESPONDENCE

Name and Address of Institution: 

Dates: From to

Graduated: Yes No

Degree Received:     Average Grades: 

Areas of Specialization: 

OTHER

Name and Address of Institution: 

Dates: From to

Graduated: Yes No

Degree Received:     Average Grades: 

Areas of Specialization: 

OTHER

Name and Address of Institution: 

Dates: From to

Graduated: Yes No

Degree Received:     Average Grades: 

Areas of Specialization: 

OTHER

Name and Address of Institution: 

Dates: From to

Graduated: Yes No

Degree Received:     Average Grades: 

Areas of Specialization: 

EMPLOYMENT RECORD

Please be accurate and give a full and complete record of your employment.  (Omit military service).  Begin with present or last position.

Present Employer: 

Nature of Business: 

Date Employed:     Wages:     Start $:    Present $:   

Your Job Title: 

Describe Your Duties: 

Immediate Supervisor - Name:    Title: 

Reason for Leaving: 

Are you presently employed?  Yes  No   If No, how long unemployed? (months):

If presently employed, when and how do you suggest we contact your present employer? 

PREVIOUS EXPERIENCE

Firm Name: 

Nature of Business:

Employed From:     Employed To: 

Wages:     Starting $:    Ending $:   

Your Job Title: 

Describe Your Duties: 

Immediate Supervisor - Name:    Title: 

Reason for Leaving: 

PREVIOUS EXPERIENCE

Firm Name: 

Nature of Business:

Employed From:     Employed To: 

Wages:     Starting $:    Ending $:   

Your Job Title: 

Describe Your Duties: 

Immediate Supervisor - Name:    Title: 

Reason for Leaving: 

PREVIOUS EXPERIENCE

Firm Name: 

Nature of Business:

Employed From:     Employed To: 

Wages:     Starting $:    Ending $:   

Your Job Title: 

Describe Your Duties: 

Immediate Supervisor - Name:    Title: 

Reason for Leaving: 

OTHER

What accomplishment has given you the greatest satisfaction?

What do you feel is your greatest asset?

Why do you want to work for this company?

What do you feel you will contribute to this company?

Current hobbies:

What do you want to be doing 10 years from now?

What has been your most interesting work?

What made it interesting to you?

What periodicals do you read regularly?

Any outside business activities?  Describe:

How did you learn about the job for which you are applying?

AFFIDAVIT (Please read carefully)

I authorize without liability investigation of all statements in this application.  I authorize all schools which I attend and all previous employers to furnish to the Company my record, reason for leaving and all information they may have concerning me and I hereby release them and the Company from all liability for any damage whatsoever arising therefrom.

I authorize my neighbors, friends or others with whom I am acquainted or who are acquainted with me to furnish the Company with information used in connection with the evaluation of my qualifications as a prospective employee.  I also authorize the making of a credit bureau investigation report whereby information may be obtained concerning my character , general reputation, personal characteristics and mode of living, whichever may be applicable.  I understand I will be notified if such an investigative report is obtained and I will have the right to make a written request within a reasonable period of time for a complete and accurate discloser of information concerning the nature and scope of the investigation.

I understand that in the event of my employment by the Company, it shall be sufficient cause for dismissal if any of the information I have given in this application is false or if I have failed to give any information herein requested.  In the event of my employment by the Company, I agree to abide by all present and subsequently issued rules of the Company.

I have read and understand the above Affidavit                      Yes    Today's Date: