Sample Employment Application Form

PLEASE PRINT ALL

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

1/14/2016
DATE ________________________________

PLEASE COMPLETE PAGES 1-4.

Schaefer
Jenna
Brooke
Name ______________________________________________________________________________________________
Last

Present address

First

Middle

Maiden

97
Shellrock Drive
Northwood, IA 50459
______________________________________________________________________________________
Number

Street

years
How long 12
____________________

City

State

Zip

xxxx
xxxx _____
xx _________
Social Security No. _______

Telephone ( xxx) xxx-xxxx

If under 18, please list age _____________________
Days/hours available to work
x
No Pref _______
Thur ________
Mon __________ Fri __________
Tue __________ Sat _________
Wed _________ Sun ________

Lifeguard
Position applied for (1) ________________________
$8/Negotiable
and salary desired (2) ________________________
(Be specific)

About 15 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

Negotiable
When available for work?_______________
____________________________________________________________________________________________________

TYPE OF SCHOOL

High School
College

NAME OF SCHOOL

LOCATION
(Complete mailing
address)

Northwood-Kensett 704 7th Street North

NIACC

Northwood, IA 50459
500 College Drive
Mason City, IA 50401

NUMBER OF YEARS
COMPLETED

3 1/2
1/2

MAJOR &
DEGREE

Diploma, May 2016

PSEO

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. __________________________________________________
____________________________________________________________________________________________________

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
IA
xxxx
number ____________________________
State of issue _______
x/xx/xxxx
Expiration date ______________________
Have you had any accidents during the past three years?
NA
Have you had any moving violations during the past three years?

NA

x Operator __ Commercial (CDL)

__

__ 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.

Deb Faugstad
Name _______________________________________

Amy Renwick
Name _____________________________________________

High School English Teacher

Position ______________________________________

High School Guidance Counselor

Position ___________________________________________

Northwood-Kensett High School

Company _____________________________________

Northwood-Kensett High School

Company __________________________________________

704 7th Street North, PO Box 289

Address ______________________________________

704 7th Street North

Address ___________________________________________

Northwood, IA 50459
______________________________________

Northwood, IA 50459
___________________________________________

Telephone (xxx) xxx-xxxx

Telephone (xxx) xxx-xxxx

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?

__ Yes __
x No

x No
__ Yes __

NA
NA
NA
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 Northwood Public Swimming Pool

Address 627 Central Ave
City, State, Zip Code Northwood, IA 50459
Phone number (641) 324-1680

Name of last
supervisor

Dedra Harris

Employment dates

From May 28th, 2015 Start

To August 15th, 2015

Your last job title

Reason for leaving (be specific)

Pay or salary

$7.75
Final $7.75

Lifeguard

SeasonalSummer Job

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Lifeguard and
Cleaning. CPR
Certified.

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

Name of last
supervisor

NA

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

NA

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

NA

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
__

If not, who did? _______________________________________________________________________________________