Employment Application
Date: __________
Last Name: ____________________ First Name: ____________________ Middle Name: _________________
Street Address: ______________________________________________________________________________
City: ___________________________________ State: __________________ Zip Code: __________________
Telephone: ____________________________________
Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may ne
required to provide documentation.) YES NO
Are you looking for full-‐time employment? YES NO
If no, what house are you available? _____________________________________________________________
Are you willing to work swing shift? YES NO
Are you willing to work graveyard? YES NO
Have you ever been convicted of a felony? (This will not necessarily affect your application.) YES NO
If yes, please describe conditions.
___________________________________________________________________________________________
___________________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________________
Desired Position: _____________________________________________________________________________
How did you hear of this opening? _______________________________________________________________
Have you ever applied for employment here? YES NO
When? ______________________________________________________________________________
Where? ______________________________________________________________________________
Have you ever been employed by this company? YES NO
When? ______________________________________________________________________________
Where? ______________________________________________________________________________
Are you presently employed? YES NO
May we contact your present employer? YES NO
Are you available for full-‐time work? YES NO
Are you available for part-‐time work? YES NO
Date you can start: ___________________________________________________________________________
Desired starting salary: ________________________________________________________________________
Please list applicable skills:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Education
School Name and Location Year Major Degree
High School: ________________________________________________________________________________
College: ____________________________________________________________________________________
College: ____________________________________________________________________________________
Post-‐College: ________________________________________________________________________________
Other Training: ______________________________________________________________________________
In addition to your work history, are there other skills, qualification, or experiences that we should
consider?____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
Please list any scholastic honors received and offices held in school.
__________________________________________________________________________________________
___________________________________________________________________________________________
Are you planning to continue your studies? YES NO
If yes, where and what course of study?
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
Employment History
(Start with most recent employer)
Company Name: _____________________________________________________________________________
Address: ___________________________________________________________ Telephone: _____________
Date Started: __________________ Starting Wage: __________________ Starting Position: _______________
Date Ended: ___________________ Ending Wage: ___________________ Ending Position: _______________
Name of Supervisor: __________________________________________________________________________
May we contact? YES NO
Job responsibilities: ___________________________________________________________________________
___________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________
Company Name: _____________________________________________________________________________
Address: ___________________________________________________________ Telephone: _____________
Date Started: __________________ Starting Wage: __________________ Starting Position: _______________
Date Ended: ___________________ Ending Wage: ___________________ Ending Position: _______________
Name of Supervisor: __________________________________________________________________________
May we contact? YES NO
Job responsibilities: ___________________________________________________________________________
___________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________
Company Name: _____________________________________________________________________________
Address: ___________________________________________________________ Telephone: _____________
Date Started: __________________ Starting Wage: __________________ Starting Position: _______________
Date Ended: ___________________ Ending Wage: ___________________ Ending Position: _______________
Name of Supervisor: __________________________________________________________________________
May we contact? YES NO
Job responsibilities: ___________________________________________________________________________
___________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________
Company Name: _____________________________________________________________________________
Address: ___________________________________________________________ Telephone: _____________
Date Started: __________________ Starting Wage: __________________ Starting Position: _______________
Date Ended: ___________________ Ending Wage: ___________________ Ending Position: _______________
Name of Supervisor: __________________________________________________________________________
May we contact? YES NO
Job responsibilities: ___________________________________________________________________________
___________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________
Company Name: _____________________________________________________________________________
Address: ___________________________________________________________ Telephone: _____________
Date Started: __________________ Starting Wage: __________________ Starting Position: _______________
Date Ended: ___________________ Ending Wage: ___________________ Ending Position: _______________
Name of Supervisor: __________________________________________________________________________
May we contact? YES NO
Job responsibilities: ___________________________________________________________________________
___________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________
Company Name: _____________________________________________________________________________
Address: ___________________________________________________________ Telephone: _____________
Date Started: __________________ Starting Wage: __________________ Starting Position: _______________
Date Ended: ___________________ Ending Wage: ___________________ Ending Position: _______________
Name of Supervisor: __________________________________________________________________________
May we contact? YES NO
Job responsibilities: ___________________________________________________________________________
___________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________
References
List three personal references, not related to you, who have known you for more than one year.
Name: _______________________________ Phone: _________________________ Years Known: _________
Address: ___________________________________________________________________________________
Name: _______________________________ Phone: _________________________ Years Known: _________
Address: ___________________________________________________________________________________
Name: _______________________________ Phone: _________________________ Years Known: _________
Address: ___________________________________________________________________________________
Emergency Contact
In case of emergency, please notify:
Name: __________________________________________________________ Phone: ____________________
Address: ____________________________________________________________________________________
Name: __________________________________________________________ Phone: ____________________
Address: ____________________________________________________________________________________
Please Read Before Signing:
I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application. I authorize my previous employers, schools, or persons listed as references to give information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees.
In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of approved documents that are required.
I understand that employment at this company is “at will,” which means that either I, or this company, can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statements.
Signature: ______________________________________________________ Date: ____________________
Please return completed applications to our facility at 11822 Old Lexington Pike, Walton, KY 41094