Application Form Personal Information Date---------------------- Name -------------------------------------------------------- Address------------------------------------------------------------------------------- Phone number------------------------------------------------ Cell------------------------------------------------------------- Employment Desired Position --------------------------------- Date available----------------------------- Salary requirement-$---------- Are you employed?------------ if so, may we contact your present employer?------------ Education High school, name and location---------------------------------------------------------------------------------------- Years attended ----------------- Date Graduated -------------------------------- Any other form of Education?---------------- Trade school ------------ How many years------------- Other --------------------------------------------------------------------------------------------------------------- Are you an American Citizen?------------------------------------ Do you have any physical defects that preclude you from performing any work for which you being considered?-------------- Former Employers list your last four employers, starting at the most recent one first Name and address of Employer Salary Position Reason Left Years/Months There #1-------------------------------------- ----------- ------------ -------------------------------------------- ----------------------------------------- #2-------------------------------------- ----------- ------------ -------------------------------------------- ----------------------------------------- #3-------------------------------------- ----------- ------------ -------------------------------------------- ----------------------------------------- #4-------------------------------------- ----------- ------------ ------------------------------------------- ----------------------------------------- Reference Name Address & Phone Years Known #1-------------------------------------------------------------------------------------------------- #2-------------------------------------------------------------------------------------------------- #3-------------------------------------------------------------------------------------------------- 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