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 ________________________________

Lloyd Danton Scott

Name ______________________________________________________________________________________________
Lloyd

Last First Middle Maiden

5 12
Present address ______________________________________________________________________________________
6th Kensett Iowa 50448
Number Street City State Zip

8 years
XXX xx xxxx
How long ____________________ Social Security No. _______ _____ _________

Telephone ( 641-530-xxxx
)

If under 18, please list age _____________________

Days/hours available to work

Carryout
Position applied for (1) ________________________ X
No Pref _______ Thur ________
Negotiable
and salary desired (2) ________________________ Mon __________ Fri __________
(Be specific) Tue __________ Sat _________
Wed _________ Sun ________

15
How many hours can you work weekly? _________________________ Yes
Can you work nights? _______________________

Employment desired __ FULL-TIME ONLY __

X PART-TIME ONLY __ FULL- OR PART-TIME
As soon as possible
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. 704 7th Street N. 3.5 HS Diploma
High School Northwood, IA 50459
College NIACC 500 COllege Drive
Mason City, IA 50401 1.5 N/A
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

My car
What is your means of transportation to work? _______________________________________________________________

Drivers license
xxxxxxxxxxx
number ____________________________ Iowa
State of issue _______ X Operator __ Commercial (CDL)
__ __ Chauffeur
7/28/19
Expiration date ______________________

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

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.

Kevin Petznick
Name _______________________________________ Aaron Christionson
Name _____________________________________________
Store Manager
Position ______________________________________ Store Manager
Position ___________________________________________
Kwik Trip
Company _____________________________________ Fallgatters
Company __________________________________________
xxxxxxxxxx
Address ______________________________________ XXXXXXXXXXX
Address ___________________________________________

______________________________________ ___________________________________________

Telephone ( XXX-XXX-XXXX
) Telephone ( XXX-XXX-XXXX
)

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.

Can work with a team well. Can

speak some Spanish. Hard
worker.
 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? __ Yes __

X No

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

Address Fallgatters supervisor
City, State, Zip Code 98 7th St N, Northwood, IA 50459
(641) 324-1651 Angie Senne From July 28, 2014 Start $7.25
Phone number
To Present Final $7.25

Your last job title Carryout

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.

Stocked products, helped customer, arranged products, made schedule.

Name of employer Name of last Employment dates Pay or salary

Address supervisor
N/A
City, State, Zip Code
From Start
Phone number
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.
 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
From Start
Phone number
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 Name of last Employment dates Pay or salary

Address supervisor
City, State, Zip Code
Phone number N/A 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? X Yes __ No

__

Did you complete this application yourself X Yes __ No

__

If not, who did? _______________________________________________________________________________________