Social Security #:

Present Address:

Permanent Address:

Phone: Age:

EMPLOYMENT DESIRED:

Position:

Date you can start: Date you can work till:

Salary Desired:

Are you employed now? Yes No | May we inquire of your employer? Yes No

Can you work weekends? Yes No | Spring? Yes No | Fall? Yes No

EDUCATION:

High School: # of years attended:

High School: # of years attended:

College: # of years attended:

College: # of years attended:

Trade: # of years attended:

Trade: # of years attended:

Do you have any physical limitations that preclude you from any work for which you are being considered? Yes No Describe:

In Case of Emergency, please notify:

FORMER EMPLOYMENT HISTORY:

Month and Year (Dates employed)	Name and Address of former Employer	Salary	Position	Reason for Leaving

"I certify that the statements contained in this application are correct to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any information regarding my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you."

Check this box if you agree to the above statement.

DATE: SIGNATURE:

E-MAIL ADDRESS: