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. January 31, 2017

DATE ________________________________

Haberman Terran Lynn

Name ______________________________________________________________________________________________
Last First Middle Maiden

1212 Marks Hill Road Northwood IA 50459

Present address ______________________________________________________________________________________
Number Street City State Zip

16 years
How long ____________________ Social Security No. _______ xx _________
xxx _____ xxxx

Telephone ( 641) 390 - xxxx

17
If under 18, please list age _____________________

Days/hours available to work

CNA at Lutheran Retirement Home
Position applied for (1) ________________________ No Pref _______ Thur ________
Negotiable
and salary desired (2) ________________________ 4:00-9:00
Mon __________ 4:00-9:00
Fri __________
(Be specific) Tue __________ Sat _________
Wed _________
4:00-9:00 Sun 12:00-
________
5:00

20 hours per week

How many hours can you work weekly? _________________________ Yes
Can you work nights? _______________________

Employment desired __ FULL-TIME ONLY __ PART-TIME ONLY X FULL- OR PART-TIME

__
May 15, 2017
When available for work?_______________

____________________________________________________________________________________________________

TYPE OF SCHOOL NAME OF SCHOOL LOCATION NUMBER OF YEARS MAJOR &

(Complete mailing COMPLETED DEGREE
address)
High School Northwood-Kensett Jr.-Sr. High 704 7th Street N. 3.5 HS Diploma
School Northwood, IA 50459
College NIACC 500 College Drive 1.5 N/A
Mason City, IA 50401
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
N/A
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
My personal vehicle.
What is your means of transportation to work? _______________________________________________________________

Drivers license
xxxxxxxxxx
number ____________________________ IA
State of issue _______ x Operator __ Commercial (CDL)
__ __ Chauffeur
xx/xx/ 2017
Expiration date ______________________

Have you had any accidents during the past three years? No How many? N/A
___________________
Have you had any moving violations during the past three years? No How Many? N/A
___________________

OFFICE ONLY

__ Yes __ Yes Word __ Yes

Typing __ No _____ WPM 10-key __ No Processing __ No _____ WPM

Personal __ Yes __ PC Other _____________________________________________

Computer __ No __ Mac Skills ______________________________________________

Please list two references other than relatives or previous employers.

Kate Hartman
Name _______________________________________ Amy Price
Name _____________________________________________
Teacher
Position ______________________________________ Teacher
Position ___________________________________________
Northwood-Kensett Schools
Company _____________________________________ Northwood-Kensett Schools
Company __________________________________________
704 7th Street N.
Address ______________________________________ 704 7th Street N.
Address ___________________________________________
Northwood, IA 50459
______________________________________ Northwood, IA 50459
___________________________________________

Telephone ( 641 ) 324- 2142 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.

N/A
 PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT

MILITARY

HAVE YOU EVER BEEN IN THE ARMED FORCES? X No

__ Yes __

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? X No

__ Yes __
N/A
Specialty ___________________________________ N/A
Date Entered ________________ N/A
Discharge Date ______________

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

Name of employer Name of last Employment dates Pay or salary

City of Northwood
Address supervisor
City, State, Zip Code
From Summer 2013 Start $8.00/hour
Phone number Susan Kliment
627 Central Ave. Northwood, Iowa, 50459 To Present Final $8.00/hour

Your last job title Lifeguard/ Swimming Lesson Instructor

Reason for leaving (be specific) Presently employed

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

Lifeguard, Swimming Lessons Instructor, Cleaning Duty, Basket house worker, Concession stand
worker,

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code N/A From Start
Phone number N/A N/A N/A
To Final

Your Last Job Title N/A

Reason for leaving (be specific) N/A

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

N/A
 PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT

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

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code
N/A N/A From N/A Start N/A
Phone number
To N/A Final N/A
Your last job title N/A

Reason for leaving (be specific) N/A

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

N/A

Name of employer Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code N/A
Phone number From N/A Start N/A
N/A
To N/A Final N/A

Your last job title N/A

Reason for leaving (be specific) N/A

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

N/A

May we contact your present employer? X Yes __ No

__

Did you complete this application yourself X No

__ Yes __
My mother Becky Haberman
If not, who did? _______________________________________________________________________________________