Sample Employment Application Form

PLEASE PRINT ALL

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

PLEASE COMPLETE PAGES 1-4.

DATE ________________________________

Tiedemann Jason Robert Kenneth

Name ______________________________________________________________________________________________
Last

First

Middle

Maiden

404 11 Street North Northwood IA 50459

Present address ______________________________________________________________________________________
Number

Street

12years
How long ____________________
Telephone (

City

State

Zip

xxxxx _____
xxxx _________
xxxx
Social Security No. _______

) (641)390-0873

If under 18, please list age _____________________

Days/hours available to work
x
No Pref _______
Thur ________
Mon __________ Fri __________
Tue __________ Sat _________
Wed _________ Sun ________

Sheriff
Position applied for (1) ________________________
Sheriffs salary
and salary desired (2) ________________________
(Be specific)

Part-Time Only
Yes
How many hours can you work weekly? _________________________
Can you work nights? _______________________
Employment desired

__ FULL-TIME ONLY

__ PART-TIME ONLY

__ FULL- OR PART-TIME

Any time
When available for work?_______________
____________________________________________________________________________________________________

TYPE OF SCHOOL

High School

NAME OF SCHOOL

Northwood-Kensett

LOCATION
(Complete mailing
address)
1200 1st Ave N
Northwood, IA

NUMBER OF YEARS
COMPLETED

MAJOR &
DEGREE

College
Bus. or Trade School
Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME?

__ No

__ Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
I have not
committed, sentence(s) imposed, and type(s) of rehabilitation. __________________________________________________
____________________________________________________________________________________________________

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT

DO YOU HAVE A DRIVERS LICENSE?

__ Yes __ No

I do have a license and I drive

What is your means of transportation to work? _______________________________________________________________
Drivers license
xxxx-xxx-xxx
xx
number ____________________________
State of issue _______
xxxx
Expiration date ______________________

__ Operator __ Commercial (CDL)

Have you had any accidents during the past three years?
Have you had any moving violations during the past three years?

__ Chauffeur

How many? ___________________

How Many? ___________________

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.

Jason Dodd

Kevin pentznick
Name _______________________________________

Name _____________________________________________

Manager
Position ______________________________________

Manager
Position ___________________________________________

Fallgatters Market
Company _____________________________________

Northwood Electric
Company __________________________________________

Address ______________________________________
98 7th St. N.

97 8th Street North, Northwood, IA 50459

Address ___________________________________________

Northwood, IA 50459
______________________________________
641-324-1651

___________________________________________

Telephone (

Telephone (

) (641) 324-2041

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?

__ Yes __ No

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?

__ Yes __ No

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
Address
City, State, Zip Code
Phone number
Doug Fallgatter 98 7th St. N.
Northwood, IA 50459 641-324-1651

Name of last
supervisor

Employment dates
From

March 17 to present
Kevin

To

Pay or salary
Start
Final 6.40-7.25

Your last job title Carry out

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 had to help stock shelves and help

people take out there groceries

Name of employer
Address
City, State, Zip Code
Phone number
97 8th Street North, Northwood, IA 50459

Name of last
supervisor

Employment dates
From

Start

To

Final $9

august 13-23

Jason Dodd

Pay or salary

Your Last Job Title electrician

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 helped lay down wire and dig trenches for

the big wires to go under the ground.

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?

__ Yes __ No

Did you complete this application yourself

__ Yes __ No

Yes you can contact my present employer

If not, who did? _______________________________________________________________________________________