logo
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  wither  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