PERSONAL INFORMATION:

Today's Date*

Last Name*

First Name*

Middle Initial

Address*

Home Phone* (include area code)

Work Phone (include area code)

E-mail*

Social Security Number*

Are you 18 or older?*
 Yes No

Have you ever interviewed with this company or its affiliates before?*
If yes, provide date(s), location(s), and position(s) applied for.

 Yes No

Have you ever been employed by this company or its affiliates?*
If yes, provide date(s), location(s), and position(s).

 Yes No

Do you have any relatives employed by this company or its affiliates?*
If yes, provide name(s), location(s), and position(s).

 Yes No

EMPLOYMENT DESIRED:

Position Applied For:*

Desired Pay*

How did you find out about this position?*

Would you like to work:
(check all that apply)
 Full-time Part-time Summer Temporary

What days/times are you available to work?*

EDUCATION:

High School:*

Name and Address
---DiplomaGEDDid Not Complete

College:

Name and Address

Graduate School:

Name and Address

Vocational, Other:

Name and Address

MILITARY:

(Leave blank if not applicable)

Branch:

Dates of Service:

Final Rank:

Assignment:

Branch:

Dates of Service:

Final Rank:

Assignment:

SKILLS:

(not all may be necessary for the job you seek)

Select any skills you possess from the list below:

 MS Excel, MS Word, SQL, Access, PowerPoint,  Visio, Project,  CRM, MS Dynamics AX, Magento, Forklift Certified, Tech Support Skills Level 1, Tech Support Skills Level 2, Tech Support Skills Level 3, Hazcom Trained, Project Management Training

Technician Skills:
 A+ Certified Board-level Repair Troubleshooting  Diagnostics

Foreign Languages:

Computer Skills (Hardware/Software):

List any other experience, skills or other qualifications including hobbies, which you believe should be considered in evaluating your qualifications for employment:

Driver's License Number:

State Issued:

License Type:

EMPLOYMENT HISTORY:

-Please list employment record, starting with the most recent.

Dates:

Employer Name and Address:

Duties, Responsibilities, Promotions:

Job Title:

Supervisor Name and Job Title:

Phone # (include area code):

Reason for Leaving:

Salary:

Employer 2:

Dates:

Employer Name and Address:

Duties, Responsibilities, Promotions:

Job Title:

Supervisor Name and Job Title:

Phone # (include area code):

Reason for Leaving:

Salary:

Employer 3:

Dates:

Employer Name and Address:

Duties, Responsibilities, Promotions:

Job Title:

Supervisor Name and Job Title:

Phone # (include area code):

Reason for Leaving:

Salary:

Employer 4:

Dates:

Employer Name and Address:

Duties, Responsibilities, Promotions:

Job Title:

Supervisor Name and Job Title:

Phone # (include area code):

Reason for Leaving:

Salary:

REFERENCES:

-Please provide three references (not relatives).

Reference 1:

Name:

Phone # (include area code):

Address:

Relationship:

Years Known:

Reference 2:

Name:

Phone # (include area code):

Address:

Relationship:

Years Known:

Reference 3:

Name:

Phone # (include area code):

Address:

Relationship:

Years Known:

GENERAL:

Are you currently employed?

If yes, may we contact your present employer?

Will you be able to perform the job functions for the position you are applying for with or without reasonable accommodation?

Have you ever been convicted of a crime?
If yes, explain.

If offered employment, will you be able to provide proof of identity and authorization to work in the U.S?

APPLICANT STATEMENT:

By checking this box I certify that I understand and agree to the following:

This application is not a contract of employment.

Should the employer hire me and should any of the information I have given in this application be found false, misleading, or incomplete, I shall be subject to dismissal.

The employer follows an “at will” employment policy, meaning I or the employer may terminate employment at any time for any reason consistent with applicable law.

All hired persons must provide proof of identity and authorization to work in the United States. Failure to produce such proof will result in denial of employment.

I authorize investigation of all statements given on this application. The employer may contact any educational institution, reference, or employer listed on this application, except my current employer if so noted, to verify the information I have given. I hereby release all involved parties from any liability arising from such an investigation.

I certify that all the information given in this application is complete and true.