Sample Employment Application Form

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS

PLEASE COMPLETE PAGES 1-4.

1/20/17
DATE ________________________________
Bachtle Brett D
Name ______________________________________________________________________________________________
Last First Middle Maiden

205 5th Ave N Northwood, IA 50459

Present address ______________________________________________________________________________________
Number Street City State Zip

10+ years
How long ____________________
xxxx xx xxxx
Social Security No. _______ _____ _________

Telephone ( 641) - 512 - 80xx

If under 18, please list age _____________________

Days/hours available to work

newscaster
Position applied for (1) ________________________ X
No Pref _______ Thur ________
negotiable
and salary desired (2) ________________________ Mon __________ Fri __________
(Be specific) Tue __________ Sat _________
Wed _________ Sun ________

as many as needed
How many hours can you work weekly? _________________________ yes
Can you work nights? _______________________

Employment desired __ FULL-TIME ONLY __ PART-TIME ONLY X FULL- OR PART-TIME

__
ASAP
When available for work?_______________

____________________________________________________________________________________________________

TYPE OF SCHOOL NAME OF SCHOOL LOCATION NUMBER OF YEARS MAJOR &

(Complete mailing COMPLETED DEGREE
address)
High School Northwood-Kensett 704 7th Street N. 3.5 HS Diploma
Jr.- Sr. High School Northwood, IA 50459
College

Bus. or Trade School

Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME? X No

__ __ Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
committed, sentence(s) imposed, and type(s) of rehabilitation. __________________________________________________

____________________________________________________________________________________________________
 PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT

DO YOU HAVE A DRIVERS LICENSE? x Yes __ No

__
vehicle
What is your means of transportation to work? _______________________________________________________________

Drivers license
xxxxxxxxxx
number ____________________________ State of issue _______ X
__ Operator __ Commercial (CDL) __ Chauffeur
xx/xx
Expiration date ______________________

Have you had any accidents during the past three years? no How many? ___________________
Have you had any moving violations during the past three years? no How Many? ___________________

OFFICE ONLY

__ Yes __ Yes Word __ Yes

Typing __ No _____ WPM 10-key __ No Processing __ No _____ WPM

Personal __ Yes __ PC Other _____________________________________________

Computer __ No __ Mac Skills ______________________________________________

Please list two references other than relatives or previous employers.

Tegan Cotter
Name _______________________________________ Elijah Coombs
Name _____________________________________________
lifeguard
Position ______________________________________ host/server
Position ___________________________________________
City of Northwood
Company _____________________________________ Diamond Jo Casino
Company __________________________________________
627 Central Ave
Address ______________________________________ 777 Diamond Jo Lane
Address ___________________________________________
Northwood, IA 50459
______________________________________
Northwood, IA 50459
___________________________________________

Telephone ( 641) 324-xxxx Telephone ( 877)323-xxxx

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the
space below to summarize any additional information necessary to describe your full qualifications for the specific position for
which you are applying.

3 years Spanish
HIPPA trained
 PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT

MILITARY

HAVE YOU EVER BEEN IN THE ARMED FORCES? X

__ Yes __ No

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? __ Yes __ No X

Specialty ___________________________________ Date Entered ________________ Discharge Date ______________

Work Please list your work experience for the past five years beginning with your most recent job held.
Experience If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer Lutheran Retirement Home Name of last Employment dates Pay or salary
Address 701 9th St N supervisor
City, State, Zip Code Northwood, IA 50459
Phone number
From April, 2015 Start $9.90
(641) 324-xxxx Nancy Franck
To current Final $10.65
Your last job title Dietary Aide
Reason for leaving (be specific) currently employed

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

resident care

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code
From Start
Phone number
To Final

Your Last Job Title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.
 PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT

Work Please list your work experience for the past five years beginning with your most recent job held.
experience If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code
From Start
Phone number
To Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code
Phone number From Start

To Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

May we contact your present employer? x Yes __ No

__

Did you complete this application yourself x Yes __ No

__

If not, who did? _______________________________________________________________________________________