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. 01/25/2017

DATE ________________________________

Coombs Elijah Carlos

Name ______________________________________________________________________________________________
Last First Middle Maiden

Present address 203 4th St. N. Northwood, IA 50459

______________________________________________________________________________________
Number Street City State Zip

15 years
How long ____________________ xxx _____
Social Security No. _______ xxxx
xx _________
Telephone (641) 390-xxxx

If under 18, please list age _____________________

Days/hours available to work

Host/Server
Position applied for (1) ________________________ x
No Pref _______ Thur ________
Negotiable
and salary desired (2) ________________________ Mon __________ Fri __________
x
Tue __________ x
Sat _________
(Be specific)
Wed _________ Sun ________x

25
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
2-3 weeks
When available for work?_______________

____________________________________________________________________________________________________

TYPE OF SCHOOL NAME OF SCHOOL LOCATION NUMBER OF YEARS MAJOR &

(Complete mailing COMPLETED DEGREE
address)
High School Northwood-Kensett 704 7th St. N. 3.5 HS Diploma
Northwood, IA 50459
College NIACC 500 College Drive 1.5 N/A
Mason City, IA 50401
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 car
What is your means of transportation to work? _______________________________________________________________

Drivers license
XXXXXXXXXXXXXXXXX
number ____________________________ IA
State of issue _______ x Operator __ Commercial (CDL)
__ __ Chauffeur
01-26-2017
Expiration date ______________________

Have you had any accidents during the past three years? How many? None
___________________
Have you had any moving violations during the past three years? How Many? None
___________________

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.

Shana Butler
Name _______________________________________ Jen Costello
Name _____________________________________________
Nurse
Position ______________________________________ Teacher
Position ___________________________________________
Worth County Public Health
Company _____________________________________ Central Springs School District
Company __________________________________________

Address xxx xth St. S. Northwood, IA

______________________________________ xxx xth St. N Manly, IA
Address ___________________________________________
50459
______________________________________ 50456
___________________________________________

Telephone ( xxx-xxx-xxxx
) Telephone ( xxx-xx-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.
 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? X No

__ Yes __

Specialty ___________________________________ Date Entered ________________ 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 City of Northwood Name of last Employment dates Pay or salary
Address supervisor
City, State, Zip Code $5.25
627 Central Ave, Northwood, IA 50459 From May 2014 Start
Phone number Suzan Kliment
(641) 324-1075 To Aug. 2015 Final $7.25

Your last job title Life Guard

Reason for leaving (be specific) Seasonal

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

Name of employer Dimond Jo Casino Name of last Employment dates Pay or salary
Address supervisor
City, State, Zip Code 777 Dimond Jo Ln Northwood, IA 50459
From Sept. 2015 Start $9.10
Phone number Tonya Davis
641-323-7777
To Present Final $9.60

Your Last Job Title Host/Server

Reason for leaving (be specific) Presently employed

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
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 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? _______________________________________________________________________________________