Application for Employment

Personal Information

First name   M. Last name   SSN number   Date (Today) Present Address   City State   ---- Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip   Present Phone No.   Are you legally employable in the US?   ---- Yes No Former Address City State ---- Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip How Long? Email Address

Position Applying For

Position Applied For   If you are applying for a position as a driver, your license# must be entered. Driver's License # Part Time or Full Time   ---- Part Time Full Time Salary Desired       Choose One   per     ---- Diem Week Date Available (e.g. 01/01/2004)   Other positions for which you feel you are qualified. State your long-range career objective. Were you referred to us? ---- Yes No If yes, by whom?

Education

Highest grade or number of years completed Grade School -- 4 5 6 7 8 High School -- 1 2 3 4 Jr. College -- 1 2 3 College -- 1 2 3 4 5 6 7 Names and Locations of Schools High School(s) City State Did You Graduate? Course of Study or Degree Earned 1 ----- Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ----- Yes No 2 ----- Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming College(s) City State 1 ----- Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ----- Yes No 2 ----- Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ----- Yes No List any special schooling: (military, correspondence, trade school, etc.)

Military Service (U.S. Armed Forces Only)

Veteran ---- Yes No Dates of service: From To Type of training received Rank achieved Branch of service Type of work performed

Physical Fitness

Present state of health ---- Excellent Good Fair Poor Your Height Your Weight Date of last hospitalization Reason How is your hearing? How is your vision? Are you willing to take physical exams at our expense? Do you have any present illness, defects or disabilities which would interfere with you performance of the job you are seeking? If so, explain:

Employment History

Employer Address Your Job Month—Year From—To Earnings Company name Street Address Name of Immediate Supervisor City, State & Zip Reason for Leaving Phone number Summarize Your Job Duties Employer Address Your Job Month—Year From—To Earnings Company name Street Address Name of Immediate Supervisor City, State & Zip Reason for Leaving Phone number Summarize Your Job Duties Employer Address Your Job Month—Year From—To Earnings Company name Street Address Name of Immediate Supervisor City, State & Zip Reason for Leaving Phone number Summarize Your Job Duties Which of the above jobs did you like best? Why? Do you prefer a job with a variety of duties? What kind of work would you like most to do, if all paid the same?

Personal Background

What are your hobbies and interests? Have you ever been convicted for any offense other than minor traffic law violations? (Give details) Personal References: Give name, address and phone of two local references other than two relatives or former employers.