Julie’s Place Employment Application Form

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE

APPLICATION FOR EMPLOYMENT

PLEASE COMPLETE PAGES 1-5.

DATE ________________________________

Name __________________________________________________________________________________________

Last First Middle Maiden

Present address __________________________________________________________________________________

Number Street City State Zip

How long ___________________

Social Security No. _______ – _____ – _________

Telephone ( )

If under 18, please list age ____________________

Position applied for (1)_______________________ and salary desired (2) ______________________ (Be specific)

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

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

Employment desired qFULL-TIME ONLY qPART-TIME ONLY qFULL- OR PART-TIME

When available for work?______________

________________________________________________________________________________________________

TYPE OF SCHOOL

NAME OF SCHOOL

LOCATION (Complete mailing address)

NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

High School

College

Bus. or Trade School

Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME? q No q 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. _______________________________________________

________________________________________________________________________________________________

DO YOU HAVE A DRIVER’S LICENSE? q Yes q No

What is your means of transportation to work? ____________________________________________________________

Driver’s license number ___________________________ State of issue _______ q Operator q Commercial (CDL) qChauffeur

Expiration date ______________________

Have you had any accidents during the past three years?

How many? __________________

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

How Many? __________________

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

Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code Phone number

From To

Start 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

Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code Phone number

From To

Start 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

Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code Phone number

From To

Start 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

Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code Phone number

From To

Start 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? q Yes q No

Did you complete this application yourself q Yes q No

If not, who did? ___________________________________________________________________________________

Please Call 386 7181 to schedule an appointment for an interview. Please fax application to

422-3619

Attention: Dave or Ben