Application for Employment

(an equal opportunity employer)

PERSONAL INFORMATION

Date_____5/25/2017_______________________________________________
Fill in upon employment
Name Malcom Zoe Y
Last First Middle Initial Social Security Number

Present Address 2700 Eaton Rapids Lansing MI 48911

Street City State Zip

Permanent Address
Street City State Zip

Phone No. ( 517 ) 6145293 Height 52 Weight 120

EMPLOYMENT DESIRED
Date Salary Range
Position Caseworker Available 5/26/17 Desired $19/hr
May We Inquire
Are You Employed Now? no Of Your Present Employer?

Have You Ever Applied to this Company Before? no Where? When?

EDUCATION
Name and Location of School No. of Years Did You Subjects Studied
Attended Graduate?
Holt High School 2 yes
High School 5885 Holt Rd, Holt, MI 48842
______________________

College ___________________________

College ___________________________

Trade, Business or
Correspondence ______________________
School

Other _____________________________

GENERAL

Subjects of Special Study or Research Work sociology

Equipment or Instruments You Can Operate Well computers

What Foreign Languages Do You Speak fluently? Read? Write?

Military Present Membership in

Service Rank National Guard or Reserves?
(CONTINUED ON OTHER SIDE)
FORMER EMPLOYERS List past employers below, starting with the most recent.

Date Name, Address and Phone of Position Salary Why did you leave?
Month and Year Employer
From___________
To
From___________
To
From___________
To
From___________
To
From___________
To

REFERENCES: Give below the names of three persons not related to you, whom you have known at least one year.
Name Address Occupation Years Acquainted
1

PHYSICAL RECORD: Do you have any physical condition which may limit your ability to perform the job applied for?
Explain:

In Case of
Emergency Notify ( )
Name Address Phone No.

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of
facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may,
regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.

Date Signature

DO NOT WRITE BELOW THIS LINE

Interviewed By Date

REMARKS:

Neatness Character
Personality Ability
Hired For Dept. Position Will Report Salary

Approved: 1. 2. 3.
Employment Manager Dept Head General Manager

Adapted with permission for student practice from Form M660-26NR Wilson Jones Company