Form  64 Application for Employment—Short Form

Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status.

Name

Last ____________________________  First _____________________ Middle_______

Date ______________

Street Address _______________________________________________________________

City _____________________  State _______  ZIP _______

Telephone _____________________ 

Social Security # _____________________

Position applied for __________________________________________

How did you hear of this opening? __________________________________________

When can you start? _____________________  Desired Wage $______________

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.) q Yes  q No

Are you looking for full-time employment? q Yes   q No

If no, what hours are you available? ______________

Are you willing to work swing shift? q Yes   q No

Are you willing to work graveyard? q Yes   q No

Have you ever been convicted of a felony? (This will not necessarily affect your application.)   q Yes   q No

If yes, please describe conditions. __________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Education        School Name and Location                                        Year      Major   Degree

High School ________________________________________       ______ ______ ______

College ___________________________________________         ______ ______ ______

College ___________________________________________         ______ ______ ______

Post-College _______________________________________         ______ ______ ______

Other Training ______________________________________        ______ ______ ______

In addition to your work history, are there other skills, qualifications, or experience that we should consider? ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Employment History   (Start with most recent employer)

Company Name ________________________________________________________________

Address ____________________________________ Telephone _________________________

Date Started ___________  Starting Wage ____________  Starting Position ________________

Date Ended _____________  Ending Wage ____________  Ending Position ________________

Name of Supervisor ____________________________________

May we contact? q Yes   q No

Responsibilities _______________________________________________________________

_____________________________________________________________________________

Reason for leaving ______________________________________________________________

Company Name ________________________________________________________________

Address ________________________________________ Telephone _____________________

Date Started ____________  Starting Wage ____________  Starting Position _______________

Date Ended _____________  Ending Wage ____________  Ending Position ________________

Name of Supervisor ____________________________________

May we contact?   q Yes   q No

Responsibilities ________________________________________________________________

______________________________________________________________________________

Reason for leaving ______________________________________________________________

Company Name _______________________________________________________________

Address _______________________________________ Telephone ______________________

Date Started ____________  Starting Wage ____________  Starting Position _______________

Date Ended _____________  Ending Wage ____________  Ending Position ________________

Name of Supervisor ____________________________________

May we contact? q Yes   q No

Responsibilities ________________________________________________________________

______________________________________________________________________________

Reason for leaving ______________________________________________________________

Company Name ________________________________________________________________

Address _______________________________________ Telephone ______________________

Date Started ____________  Starting Wage ____________  Starting Position _______________

Date Ended _____________  Ending Wage ____________  Ending Position ________________

Name of Supervisor ____________________________________

May we contact? q Yes   q No

Responsibilities ________________________________________________________________

______________________________________________________________________________

Reason for leaving ______________________________________________________________

Attach additional information if necessary.

I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal. This company is hereby authorized to make any investigations of my prior educational and employment history.

I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, or executive of this company, other than the president, has any authority to alter the foregoing.

 

Signature____________________________    Date _________________