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Personal Information

Name:
Social Security Number :
Address :
APT. #:
City:
State:
Zip:
Are you 18 years old or older:
 Yes No
Desired Employment
Position:
Date you can start :
Salary desired :
Are you employed now: Yes No
If so may we inquire of your present employer :
 Yes No
Have you ever applied to this company before :
 Yes No
If yes where:
When:
Have you ever worked for this company before :
Yes No
If yes where:
When:
Reason for leaving:
Name of last supervisor at this company :
Who referred you to this company :
 Employment Agency
Newspaper Advertising
Friend
State Employment Office
College Placement Service
Walk In
Other
Education
Grammar School (Name and Location):
Number of years attended :
Did you graduate: Yes No
Subjects studied:
 
High School (Name and Location):
Number of years attended :
Did you graduate: Yes No
Subjects studied:
College (Name and Location):
Number of years attended :
Did you graduate: Yes No
Subjects studied:
 
Trade, Business or Correspondence
School (Name and Location):
Number of years attended :
Did you graduate: Yes No
Subjects studied:

General

Subjects of special study or research work :
Special Training :
Special Skills :
 
Former Employers
List below the last three employers, starting with the most recent one first
Name of Present or Last Employer :
Address :
City:
State:
Zip:
Starting Date :
Ending Date :
Job Title :
Weekly starting salary:
Weekly ending salary:
May we contact your supervisor: Yes No
Title :
Phone:
Description:
Reason for leaving :
 
Name of Previous Employer :
Address :
City:
State:
Zip:
Starting Date :
Ending Date :
Job Title :
Weekly starting salary:
Weekly ending salary:
May we contact your supervisor: Yes No
Name of Supervisor :
Title :
Phone:
Description:
Reason for leaving :
 
Name of Previous Employer :
Address :
City:
State:
Zip:
Starting Date :
Ending Date :
Job Title :
Weekly starting salary:
Weekly ending salary:
May we contact your supervisor: Yes No
Name of Supervisor :
Title :
Phone:
Description:
Reason for leaving :
 
References
Below,give the names of three person you are not related to, whom have known you at least one year.
Name :
Address :
City:
State:
Zip:
Business :
Years Acquainted :
 
Name :
Address :
City:
State:
Zip:
Business :
Years Acquainted :
 
Name :
Address :
City:
State:
Zip:
Business :
Years Acquainted :
 
Service Record
Branch of Service :
Rank :
Discharge Date :
 
Background.
Have you been convicted of a
felony within the last 5 years :		 Yes No
If Yes Explain:
 

Authorization
"I certify that the fact contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be ground for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative."

I Agree I Disagree

Email:

 

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©2005 Don Dickel Floors, 128 Main St. Winterport, ME 04496