Job Application

Personal Information

Last Name

First Name

Middle Name

Street Address

City

State

Zip Code

County

Telephone (with area code)

Social Security Number

Are you legally permitted to work in the United States? Yes No

Are you under 18 years of age? Yes No

In Indiana, are you under 21 years of age? Yes No

In Kentucky, are you under 20 years of age? Yes No

Employment Information

Position you are applying for

Date available to start

Salary Desired

Are you currently employed? Yes No

If so, my we inquire of your present employer?

Are you available to work: Full-time Part-time Shift Work

Referral Source

Walk-in Advertisement Employee
Employment Agency Other

If referral source is an employee, employment agency, or other, please specify

Education

High School

Location (City, State, Zip)

Graduate?

College or University

Location

Graduate?

Degree Received

Major Course of Study

Trade/Vocational School

Location

Graduate?

Degree Received

Major Course of Study

Other School Attended

Location

Graduate?

Degree Received

Major Course of Study

U.S. Military or Naval Service

Rank

During the past 7 years, have you ever been convicted of a crime, excluding minor traffic violations?

Yes No

If yes, please describe in full

SKILLS

Personal Computer Beginner Intermediate Advanced

Microsoft Word Beginner Intermediate Advanced

Powerpoint Beginner Intermediate Advanced

Excel Beginner Intermediate Advanced

Access Beginner Intermediate Advanced

Word Perfect Beginner Intermediate Advanced

MS Exchange Beginner Intermediate Advanced

Lotus Beginner Intermediate Advanced

Typing Beginner Intermediate Advanced

10 Key Calculator Beginner Intermediate Advanced

Foreign Lanuage Beginner Intermediate Advanced

Specify Language

Other Skills

Previous Employment Information

Employer One

Name

Address

City, State, Zip

Phone

Start Date

End Date

Immediate Supervisor

Starting Wage

Ending Wage

Position Held & Job Duties

Reason(s) for Leaving

Explain all time between jobs (must be answered for processing)

Employer Two

Name

Address

City, State, Zip

Phone

Start Date

End Date

Immediate Supervisor

Starting Wage

Ending Wage

Position Held & Job Duties

Reason(s) for Leaving

Explain all time between jobs (must be answered for processing)

Employer Three

Name

Address

City, State, Zip

Phone

Start Date

End Date

Immediate Supervisor

Starting Wage

Ending Wage

Position Held & Job Duties

Reason(s) for Leaving

Explain all time between jobs (must be answered for processing)

Professional References

Reference One

Name

Address

City, State, Zip

Phone Number (with area code)

Years Known

Occupation

Reference Two

Name

Address

City, State, Zip

Phone Number (with area code)

Years Known

Occupation

Reference Three

Name

Address

City, State, Zip

Phone Number (with area code)

Years Known

Occupation


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