21THINGS4STUDENTS

Employment Application

APPLICANT INFORMATION
Last Name

AcMoody

Street Address

First

Lydia

M.I. M

City

Coldwater

Stat
e

Phone

5172799555

E-mail Address
Social
Security No.

Anytime

Position Applied for

MI

ZIP

Have you ever worked for this company?

Have you ever been convicted of a felony?

17.acmoolm@ccscards.org
Desired
Wage:

123-45-6789

YES

YES

YES

NO

If no, are you authorized to work in the U.S.?

NO

If so, when?

NO

If yes, explain

Address

275 N. Fremont St. Coldwater, MI 49036

YES

NO

Address

175 Green St. Coldwater, MI 49036

YES

NO

EDUCATION (PLEASE LIST MOST RECENT FIRST)

From
School 2

Coldwater High School

2013

To

2017

Did you
graduate?

Legg Middle School

From

2010

School 3

Lakeland Elementary School

From

2004

To

To

2013

2010

Did you
graduate?

NOT YET

Address
Did you
graduate?

YES

NO

REFERENCES
Please list three professional references you have known at least 3 years and are not friends or relatives.
Full Name

Jennifer Milligan

Relationship

Company

Coldwater High School

Phone

Full Name

Donna Hines

Relationship

Company

Edward Jones Investments

Phone

Full Name

Alison Harwell

Relationship

Company

Branch Area Careers Center

Phone

Teacher

Address
Ag Teacher

Address

Address

49036

$13 an hour to begin

Office Worker

Are you a citizen of the United States?

School 1

5-12-15

Apartment/Unit
#

275 N. Fremont St.

Date Available

Date

Ag Teacher

YES

NO

PREVIOUS EMPLOYMENT
Company
: Albright
Swine
Farms

Phone:

Address

Supervis
or
Starting
Salary

Job Title

Responsibilitie
s
From:
To:
Reason for Leaving
2015
2013
May we contact your previous supervisor for a
reference?

$10 an hour

Ending
Salary

$10 an hour

Ending
Salary

Ending
Salary

Winter Job
YES

NO

Company

Phone

Address

Supervis
or
Starting
Salary

Job Title

Colleen Albright

Responsibilitie
s
From

To

Reason for Leaving

May we contact your previous supervisor for a

reference?

YES

NO

Company

Phone

Address

Supervis
or
Starting
Salary

Job Title

Responsibilitie
s
From

To

Reason for Leaving

May we contact your previous supervisor for a

reference?

YES

NO

MILITARY SERVICE
Branch
---Rank at
Discharge-----If other than honorable,
explain------

Fro
m

------

To

------

Type of Discharge

------

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview
may result in my release.
Signature

Lydia
AcMo
ody

Date

5-12-15