PERSONAL INFORMATION Date_____/_____/_____
Name: First _______________________ M.I._______ Last _________________________
Are you 18 or older________?
Address:_______________________________ City___________________ State ______ Zip ___________
Phone: ___________________ Referred By :_________________________
Ever convicted of a felony Yes____ No____
What was the last grade of school completed _____________? Degree_______________?
Social Security #_______________
EMPLOYMENT DESIRED
Position___________________ Date you can start _____/_____/_____ Salary Desired $_____________
Are you employed Yes_____ No_____ If, so can we inquire of your present employer Yes_____ No_____
Days and Times you are available to work:
DAYS: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
TIMES: ________ _________ _________ __________ _________ _________ _________
How many hours would be optimal for you to work per week ? ___________
FORMER EMPLOYERS
1) Dates: Mo & Yr ___/___ ___/___ _____________________ $______ __________ ____________________
From: To: Name and Address of Employer Salary Position Reason for leaving
2)
Dates: Mo & Yr ___/___ ___/___ _____________________ $______ __________ ____________________
From: To: Name and Address of Employer Salary Position Reason for leaving
3)
Dates: Mo & Yr ___/___ ___/___ _____________________ $______ __________ ____________________
From: To: Name and Address of Employer Salary Position Reason for leaving
What job have you enjoyed most?_________________
What were your responsibilities?______________________________
What is your best personal quality to offer an employer ___________________________?
REFERENCES
Name Address Business Phone Years Known
1) ______________________ _____________________ __________________ ___________ ___________
2) ______________________ _____________________ __________________ ___________ ___________
3) ______________________ _____________________ __________________ ___________ ___________
Are you a U. S. Citizen YES or NO
Date _____/_____/_____ Signature_____________________________________
_______________________________________ Do Not Write Below This Line_____________________________________________
REMARKS___________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Interviewed By: ______________________ Date _____/_____/_____ Hired: Yes_____ No_____ Salary $_______