[]  To produce a one-piece employment application form for your
company, consider editing and printing the following four
pages, copying them onto 11"x 17"paper, and folding the paper
to 8.5" x 11" size.

                   Application for Employment
                         (Please Print)

We are an equal opportunity employer, dedicated to a policy of
non-discrimination in employment on any basis including age, sex,
color, race, creed, national origin, religious persuasion,
marital status, political belief, or disability that does not
prohibit performance of essential job functions.

                              Date: ________________

I. Personal Information

_____________________________________________________________________
Name:      Last                    First                 Middle

_____________________________________________________________________
Present Address

_____________________________________________________________________
Permanent Address (if different than above)

___________________________          ________________________________
Social Security Number               Telephone

Federal law prohibits the employment of unauthorized aliens. All
persons hired must submit satisfactory proof of employment
authorization and identity (valid drivers license, birth
certificate, Green Card, etc.) within three days of being hired.
Failure to submit such proof within the required time shall
result in immediate employment termination.

Position Applied For:  ______________________________________________

1.  Is there any information we would need about your name or use
of another name for us to be able to check your work record?
Please specify: _____________________________________________________

_____________________________________________________________________

2.  Do you have any relatives who are presently (or have formerly
been) employed by (Company)?

_____________________________________________________________________

3.  How were you referred to [Company]? _____________________________

4.  Have you ever been convicted of a felony? __ Yes   __ No
If yes, please explain:

_____________________________________________________________________

_____________________________________________________________________

II. Educational History

  School Name/Location      Years Completed   Degree/Diploma

Elem/Jr. High _______________________________________________________

High School _________________________________________________________

College _____________________________________________________________

Tech. Training ______________________________________________________

Other _______________________________________________________________


III. Employment Record  Please include all employment for the last
five years.

1. ____________________________                    __________________
   Company Name (Current or Most Recent Employer)  Position Held

  _____________________________    Dates Employed: __________________
  Address                                          From     To

  ____________________________     __________________________________
  Manager / Supervisor             Telephone        Wage/Salary

  ___________________________________________________________________
  Reason For Leaving

2. ___________________________     _________________________________
   Company Name                    Position Held

  ____________________________     Dates Employed: ________________
  Address                                          From     To

  ____________________________     __________________________________
  Manager / Supervisor             Telephone        Wage/Salary

  ___________________________________________________________________
  Reason For Leaving

3. ___________________________     __________________________________
   Company Name                    Position Held

  ____________________________     Dates Employed: __________________
  Address                                          From    To

  ____________________________     __________________________________
  Manager / Supervisor             Telephone        Wage/Salary

  ___________________________________________________________________
  Reason For Leaving

NOTE:  Use a separate sheet to list additional employers, if necessary
We will contact all of the employers listed on this application unless
you specifically exclude them below. Please list any employers you do
not want us to contact and your reason for the exclusion:

  ____________________________     __________________________________
  (Employer's Name)                Reason

  ____________________________     __________________________________
  (Employer's Name)                Reason


IV. References  Please do not include relatives or former employers.

1.  ___________________________________     _________________________
    Name                                    Years Known

    ___________________________________     _________________________
    Address                                 Telephone

    ___________________________________
    Occupation

2.  ___________________________________     _________________________
    Name                                    Years Known

    ___________________________________     _________________________
    Address                                 Telephone

    ___________________________________
    Occupation

3.  ___________________________________     _________________________
    Name                                    Years Known

    ___________________________________     _________________________
    Address                                 Telephone

    ___________________________________
    Occupation


V. Work Availability

1.  If your application receives favorable consideration, when will
you be available to begin work? _______________________

2.  Do you have any objection to working overtime? (  ) Yes  (  ) No
3.  Can you work overtime without prior notice?    (  ) Yes  (  ) No
4.  Can you work on Saturday?                      (  ) Yes  (  ) No
5.  Can you work on Sunday?                        (  ) Yes  (  ) No
6.  Can you travel if required by this position?   (  ) Yes  (  ) No


VI. Salary / Hourly Rate Requirements

If your application receives favorable consideration, what salary/
hourly rate would you require?

$ _________  per _________

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