How were you referred to us:

Position Applied for:

Date Available to Start:

If you are under 18 and we require a work permit, can you furnish one?

Yes No

If 'No', please explain:

Have you ever worked for this company?

Yes No

Are you a citizen of the United States?

Yes No

If not, are you legally allowed to work in the United States?

Yes No

Type of employment desired:

Full-Time Part-Time Seasonal Temporary

Have you ever pleaded "guilty" or "no contest" or been convicted of a crime

Yes No

If yes, give dates and details:

Driver's License number if applicable to position:

Summarize your Special Skills or Qualifications:

Starting Salary and Title:

Ending Salary and Title:

May we contact this Employer for a Reference?

Yes No

Starting Salary and Title:

Ending Salary and Title:

May we contact this Employer for a Reference?

Yes No

Starting Salary and Title:

Ending Salary and Title:

May we contact this Employer for a Reference?

Yes No

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquires of my personal, employment, educational, financial and other related matters as may be necessary for an employment decision. I hereby release employers, schools, or individuals from all liability when responding to inquires in connection with my application. In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge.

OUR COMPANY

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Employment Application

Burlington, KS

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