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.

DATE ________________________________

Jorgensen
Jenna
Nicole
Name ______________________________________________________________________________________________
Last

First

Middle

Maiden

2206
Northwood
IA 50459
485th
Present address ______________________________________________________________________________________
Number

Street

One year
How long ____________________

City

State

Zip

xxx
xx
xxxx
Social Security No. _______
_____
_________

Telephone (xxx ) xxx-xxxx

17
If under 18, please list age _____________________
Days/hours available to work
No Pref _______ Thur ________
x
Mon __________ Fri __________
x
Tue __________ Sat _________
x
Wed _________ Sun ________

Waitress
Position applied for (1) ________________________
and salary desired (2) ________________________
Negotiable
(Be specific)

How many hours can you work weekly? _________________________

Can you work nights? _______________________
Yes
25
Employment desired

__ FULL-TIME ONLY

__ PART-TIME ONLY

__
x FULL- OR PART-TIME

When available for work?_______________

Immediately
____________________________________________________________________________________________________

TYPE OF SCHOOL

High School
College

NAME OF SCHOOL

LOCATION
(Complete mailing
address)
Northwood Kensett 704 7th St. N
Northwood, IA 50459
NIACC
500 College Dr
Mason City, IA 50401

NUMBER OF YEARS
COMPLETED
3.5

MAJOR &
DEGREE
Diploma, 16

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
Iowa
xxxxxxxx
number ____________________________
State of issue _______
COMPLETE
Expiration date ______________________
Have you had any accidents during the past three years?
Have you had any moving violations during the past three years?

__
x Operator __ Commercial (CDL)

__ Chauffeur

No
How many? ___________________
How Many? ___________________
NO

OFFICE ONLY

Typing

x Yes
__
__ No

Personal
Computer

__ Yes
__
x No

_____ WPM

__ Yes
10-key __ No

__ PC
__ Mac

Word
Processing

x Yes
__
__ No

_____ WPM

Other _____________________________________________
Keynote, numbers, google docs
Skills ______________________________________________

Please list two references other than relatives or previous employers.

Name _______________________________________
Stephanie Hengesteg

Name _____________________________________________
Jake Hansen

Position ______________________________________
Motor Vehicle Deputy

Position ___________________________________________
Worth County Treasurer

Company _____________________________________
Worth County Treasurers Office

Company __________________________________________
Worth County Treasurers Office

822 Central Avenue

Address ______________________________________

822 Central Avenue

Address ___________________________________________

______________________________________

___________________________________________

Telephone (641-) 324-2942

Telephone (641-) 324-2942

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?

X No
__ Yes __
X No
__ Yes __

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?

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 Ty Peterson

Address
416 William St.
City, State, Zip Code Carpenter, Iowa, 50426
Phone number (641)736-4512

Name of last
supervisor

Dedra Harris

Employment dates

Pay or salary

Start $7.00
October, 2014
To Present
Final $7.00
From

Your last job title Certified Lifeguard

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.

A skill that I have learned while working here is communication.

I have properly learned how to load a dishwasher and clean dishes.

I have learned some of the safety regulations for different types of food the business serves.
I stock the shelves and prepare some foods before being served.
I have learned how to properly cut vegetables, meats, and different types of cheese.

Name of employer Dedra Harris

Address Text
City, State, Zip Code Northwood, IA, 50459
Phone number 641-324-1680

Name of last
supervisor

Employment dates
From

May, 2011
To Present

Pay or salary
Start $7.50
Final &7.50

Your Last Job Title

Reason for leaving (be specific)

Present

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

I have completed lifeguard training, including CPR.

I have been able to teach young children ages 2-12 swimming lessons.

I have developed communication skills.

Throughout my years working at the Northwood Swimming Pool my pay has increased by fifty cents.
(The max amount to be paid.)

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

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

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?

__ Yes __ No

Did you complete this application yourself

__ Yes __ No

If not, who did? _______________________________________________________________________________________