Sample Employment Application Form

PLEASE PRINT ALL

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

January 14, 2015

DATE ________________________________

PLEASE COMPLETE PAGES 1-4.

N/A
Hagen
Shelby
Nicole
Name ______________________________________________________________________________________________
Last

First

Middle

Maiden

4606 Wheelerwood Rd.

Northwood
IA
50459
Present address ______________________________________________________________________________________
Number

Street

City

17 years
How long ____________________

State

Zip

XXXX _____
XXX _________
XXXX
Social Security No. _______

Telephone (641) 324-XXXX

17
If under 18, please list age _____________________
Days/hours available to work
5-9 p.m.
No Pref _______ Thur ________
5-9 p.m.
5-9 p.m.
Mon __________
Fri __________
5-9 p.m.
1-9 p.m.
Tue __________
Sat _________
5-9 p.m.
1-9 p.m.
Wed _________
Sun ________

cashier
Position applied for (1) ________________________
$8.00
and salary desired (2) ________________________
(Be specific)

around 20 hours
yes
How many hours can you work weekly? _________________________ Can you work nights? _______________________
Employment desired

X PART-TIME ONLY
__

__ FULL-TIME ONLY

__ FULL- OR PART-TIME

evenings and weekends

When available for work?_______________
____________________________________________________________________________________________________

TYPE OF SCHOOL

NAME OF SCHOOL

High School

Northwood-Kensett

College

NIACC

LOCATION
(Complete mailing
address)

704 7th St. N

PO Box 289

NUMBER OF YEARS
COMPLETED

4
1

MAJOR &
DEGREE

Generals
English course

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. __________________________________________________
N/A
____________________________________________________________________________________________________

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT

DO YOU HAVE A DRIVERS LICENSE?

X Yes __ No
__

personal vehicle
What is your means of transportation to work? _______________________________________________________________
Drivers license
XXX XX XXXX
Iowa
number ____________________________
State of issue _______
02/20/1997
Expiration date ______________________
Have you had any accidents during the past three years? No
Have you had any moving violations during the past three years? No

X Commercial (CDL)
__ Operator __

__ Chauffeur

N/A
How many? ___________________
How Many? ___________________
N/A

OFFICE ONLY

Typing

__ Yes
__ No

Personal
Computer

__ Yes
__ No

_____ WPM

__ Yes
10-key __ No

__ PC
__ Mac

Word
Processing

__ Yes
__ No

_____ WPM

Other _____________________________________________
Skills ______________________________________________

Please list two references other than relatives or previous employers.

Beth Butler

Amy Renwick
Name _____________________________________________

Teacher

Position ______________________________________

School counselor
Position ___________________________________________

Northwood-Kensett Schools
Company _____________________________________

Northwood-Kensett School
Company __________________________________________

704 7th St N
Address ______________________________________

704 7th St N
Address ___________________________________________

Name _______________________________________

Northwood, IA 50459

______________________________________
Telephone (641-324-2142
)

Northwood, IA 50459
___________________________________________
Telephone (641-324-2142
)

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.

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
MILITARY
HAVE YOU EVER BEEN IN THE ARMED FORCES?
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?

X No
__ Yes __
X No
__ Yes __

N/A
N/A
N/A
Specialty ___________________________________
Date Entered ________________
Discharge Date ______________
Work
Experience

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

Name of employer Bryn Pangburn

Address North Star Xpress, 8th St. North
City, State, Zip Code Northwood, IA 50459
Phone number (641) 324-1792

Name of last
supervisor
Bryn Pangburn

Employment dates

Pay or salary

From June 2013

Start

$7.25

To Present

Final

$8.50

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.
I am a prep cook, dish washer, server, and cashier.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last
supervisor

Employment dates

Pay or salary

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.

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
Work
experience

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

Name of employer
Address
City, State, Zip Code
Phone number

Name of last
supervisor

Employment dates

Pay or salary

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.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last
supervisor

Employment dates

Pay or salary

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
__

N/A
If not, who did? _______________________________________________________________________________________