Print, practice filling out this job application form, and use it as a guide when completing applications for

employment.
Then, review more job applications and information on applying for jobs.

Job Application Form

Instructions: Print clearly in black or blue ink. Answer all questions. Sign and date the form.
PERSONAL INFORMATION:
First Name _____________Dalton________________
Middle Name _________Thomas__________________
Last Name __________Langley___________________
Street Address
_______________________________________________________
City, State, Zip Code
____________35594___________________________________________
Phone Number
(205)412-3670____________________________
Are you eligible to work in the United States?
Yes ___x____ No_______
If you are under age 18, do you have an employment/age certificate?
Yes ___ No __x__
Have you been convicted of or pleaded no contest to a felony within the last five years?
Yes_______ No____x____
If yes, please explain: _________________________________________
__________________________________________________________
POSITION/AVAILABILITY:
Position Applied For
_____________orthodonist___________________________
Days/Hours Available
Monday __x__
Tuesday _x__
Wednesday __x__
Thursday __x__
Friday __x__
Saturday __none__
Sunday __none__

Hours Available: from ___7:00 A.M.____ to __5:00 P.M.____

What date are you available to start work?
________________Any time________________________
EDUCATION:
Name and Address Of School - Degree/Diploma - Graduation Date
Winfield City High School 232 Pirate Cove May of 2017____________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Skills and Qualifications: Licenses, Skills, Training, Awards
___________________Steady hands, eager to work, highschool
education__________________________________________
_____________________________________________________________
EMPLOYMENT HISTORY:
Present Or Last Position:
Employer: _____________________________________________________
Address:______________________________________________________
Supervisor: ____________________________________________________
Phone: _______________________________
Email: ________________________________
Position Title: _________________________
From: ______________ To: ______________
Responsibilities: ____________________________________________________
__________________________________________________________
Salary: _______________
Reason for Leaving: ____________________________________________
===========
Previous Position:

Employer: _____________________________________________________
Address:______________________________________________________
Supervisor: ____________________________________________________
Phone: _______________________________
Email: ________________________________
Position Title: _________________________
From: ______________ To: ______________
Responsibilities: ___________________________________________________
__________________________________________________________
Salary: _______________
Reason for Leaving: ____________________________________________
May We Contact Your Present Employer?
Yes _____ No _____
References:
Name/Title Address Phone
Mrs. Guin, Coach Parish, __________________________________________
_________________________________________________________________
_________________________________________________________________
I certify that information contained in this application is true and complete. I understand that false information may
be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I
authorize the verification of any or all information listed above.
Signature_Dalton Langley_____________________________
Date_______4/16/14___________________________