Fairmont True Value

462 S. State St . Fairmont, MN 56031
507-235-8783 . Fax: 507-235-8856

Lakefield True Value
304 Main St . Lakefield, MN 56150
507-662-5100 . Fax: 507-662-5570

APPLICANT INFORMATION
Full Name:

_______________________________________________________
Last
First
M.I.

Date: ______________________

Address: ____________________________________________________________________________________
Street Address Apartment/Unit #
____________________________________________________________________________________
City State Zip Code
Phone:

_______________________________

Date Available: _______________

Email: _____________________________________________

Social Security No: __________________

Position Applied For: ______________________________________________
YES NO

Are you a citizen of the United States?

Full Time

Part Time

If no, are you authorized to work in the U.S.?

YES NO

Have you ever worked for this company?
Have you ever been convicted of a felony?

Desired Salary: _$_____________

YES NO

If yes, when? _________________________________________

YES NO

If yes, explain: ____________________________________________________________________________________

EDUCATION
High School: _____________________________
From: ____________

To: ____________

YES NO

Did you graduate?

College: _________________________________
From: ____________

To: ____________

Address: ______________________________________________
Diploma: __________________________

Address: ______________________________________________
YES NO

Did you graduate?

Degree: __________________________

REFERENCES
Please list two professional references.
Full Name: ______________________________________________

Relationship: ___________________________

Company: _______________________________________________

Phone: ________________________________

Address: ________________________________________________________________________________________

Full Name: ______________________________________________

Relationship: ___________________________

Company: _______________________________________________

Phone: ________________________________

Address: ________________________________________________________________________________________
PREVIOUS EMPLOYMENT
Company: _______________________________________________
Address: ____________________________________________
Job Title: __________________________

Phone: ________________________________

Supervisor: ________________________________

Starting Salary: _$______________

Ending Salary: _$______________

Responsibilities: __________________________________________________________________________________
From: ____________

To: ____________

Reason for Leaving: __________________________________________

May we contact your previous supervisor for a reference?

YES NO

Company: _______________________________________________
Address: ____________________________________________
Job Title: __________________________

Phone: ________________________________

Supervisor: ________________________________

Starting Salary: _$______________

Ending Salary: _$______________

Responsibilities: __________________________________________________________________________________
From: ____________

To: ____________

Reason for Leaving: __________________________________________

May we contact your previous supervisor for a reference?

YES NO

DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment,
I understand that false or misleading information in my application or interview may result in my release.
Signature: _________________________________________________________

Date: _______________________

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