Application for Employment

Personal Information
Date	     	
Name	     	Social Security No.	     	
Present Address	     	
Permanent Address	     	
Phone Number	     	Referred by	     	

Employment Desired
Position	     	Date Available	     	Salary Req.	     	
Are you employed?	   	If so, may we inquire of your present employer	   	
Ever applied to this company?	   	Where?	   	When?	   	

Education
	Name & Location of School	*Years Attended	*Date Graduated	Area of Study	
Grammar School	     	     	     	     	
	     				
High School	     	     	     	     	
	     				
College	     	     	     	     	
	     				
Trade, Business or	     	     	     	     	
Correspond. School	     				

General
Subjects of Special Study or Research Work	     	
What foreign languages do you speak fluently?	     	
Read	     	Write	     	
U.S. Military Service	     	Rank	     	
Member of National Guard/Reserves?	     	
								
	U.S. Citizen		yes		no			
					
	Date of Birth*			
* The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

Physical Record
Do you have any physical defects that preclude you from performing any work for which 	
you are being considered?	     	
				
Where you ever injured?	     	Give Details:	     	
	
Have you any defects in hearing?	   	In vision?	   	In speech?	   	
In case of emergency, notify:	     	

Former Employers
(List below your last four employers, starting with the most recent one first.)
Date (M/Y)	Name & Address of Employer	Salary	Position	Reason Left	
From:	     	     	     	     	     	
To:	     	     				
From:	     	     	     	     	     	
To:	     	     				
From:	     	     	     	     	     	
To:	     	     				
From:	     	     	     	     	     	
To:	     	     				

References
	Name	Address & Phone	Business	Years Known	
1	     	     	     	     	
2	     	     	     	     	
3	     	     	     	     	

SIGNATURE_______________________________________DATE________________

DO NOT WRITE BELOW THIS LINE
______________________________________________________________________
Remarks
Appearance:	     	Character:	     	
Personality	     	Ability	     	
Hired:	     	For Dept.:	     	Position	     	
Will Report:	     	Salary/Wages	     	
Approved	1.	     	2.	     	3.	     	
Employment Manager:	     	Dept. Head:	     	
General Manger	     	

This form has been designed to comply with State and Federal Fair Employment Practice laws prohibiting discrimination on the basis of an applicant’s sex or minority status. Questions directly or indirectly reflecting such status have been included only where needed to determine a bona fide occupational qualification or for other permissible purposes. Such questions are appropriately noted on the application. Notwithstanding these efforts, the manufacturer of this form assumes no responsibility, and hereby disclaims any liability for inclusion in this form, of any questions upon which a violation of State and Federal Fair Employment Practice laws may be based.