Printable Job Application

Application for Employment

Please fill out form completely for employment consideration. Print and fax or mail when
completed.

Prospective employees will receive consideration without discrimination because of race, creed,
color, sex, age, national origin or handicap. We are an equal opportunity employer.
Personal Information
Last Name First Middle Date
Hepperly Hailey Ann 1/9/18
Street Address Home Phone
( )
1724 430th St XXX-XXX-XXXX -
City, State, Zip

Northwood, IA 50459
Business Phone Email Address:
( ) -
XXX-XXX-XXXX
What was your previous address? How long at present
address?

_________
N/A Years
N/A ________
N/A Months
Are you over 18 years of age? Yes No How long at present
If not, employment is subject to verification of minimum legal age. address?

_________
N/A Years
________
N/A Months
Have you ever applied for employment with us? Social Security No.
Yes No
If Yes: Month and Year__________
N/A Location______________________________
N/A - -

How did you learn of our organization?

N/A
Are you legally eligible for employment in the United States? When will you be able to work?

Yes. I am eligible for employment in the United States. Select Days throughout the year.
Are you employed now? If so, may we inquire of your present employer?
Yes. Phone. Email.

Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary
offenses, which has not been annulled, expunged or sealed by a court? Yes No If
Yes, describe in full.

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Printable Job Application

Are there any reasons for which you might not be able to perform the job duties (with a
reasonable accommodation)?
Yes No If Yes, please explain.

Drivers License# State Any Violations?

XXXXXXXXX IA Yes No

Education

No. of
Course of Did you Degree or
School Name and location of school years
study graduate? diploma
completed
College Yes
North Iowa Community College Generals Less than 1 year No N/A
High Yes
Northwood-Kensett High School Generals 4 years No N/A
Trade Yes
School No
Other Yes
No

Military
Complete this section if you served in the U.S. Armed Forces Branch of Service

N/A N/A
Describe your duties and any special training Period of Active Duty (Month & Year)

From N/A To N/A

Rank at Discharge N/A
Date of Final Discharge
N/A N/A

Employment History Please give accurate, complete full-time and part-time employment
record. Start with present or most recent employer.

Company Name Telephone

Mills Fleet Farm (XXX-XXX- ) -
XXXX
Address Employed (Start Month and Year)
: Aug. 2015; Aug 2016
3200 4th St SW, Mason City, IA 50401 From : July 2015; July 2016 To
1.
Name of Supervisor Hourly Rate
$8.50(weekdays) $10.50( weekend
Nicole Start Last
$8.50(weekdays) $10.50( weekend
Start Job Title and Describe Your Work Reason for Leaving

Cashier. Scanning items. Still at job.

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Printable Job Application

Company Name Telephone

Diamond Jo Casino (XXX-XXX-XXXX
) -
Address Employed (Start Month and Year)

777 Diamond Jo Ln, Northwood, IA 50459 From : April 2016 To: Dec. 2016
2.
Name of Supervisor Hourly Rate

Tonya Start $10.50 Last $10.50

Start Job Title and Describe Your Work Reason for Leaving

Cleaning dishes from the whole casino. New job opportunity

Company Name Telephone
Pioneer Seeds (XXX-XXX-XXXX
) -
Address Employed (Start Month and Year)

July 2015/ Aug 2015/Aug 2016

129 Industrial Dr, Forest City, IA 50436 From To
3. July 2016
Name of Supervisor Hourly Rate

Bob Miller Start $8.00 Last $9.00

Start Job Title and Describe Your Work Reason for Leaving

Detassler. Picking tassels off of female corn. Seasonal Position.

Company Name Telephone
City of Northwood (XXX-XXX-XXXX
) -
Address Employed (Start Month and Year)

Northwood, Ia From : May 2014; May 2015 To Aug 2014;

4. Aug 2015
Name of Supervisor Hourly Rate

Dedra Harris Start $5.25 Last $5.25

Start Job Title and Describe Your Work Reason for Leaving

Concession Stand worker. Preparing foods and counting inventory. New Job.
Do not contact
We may contact the employers listed above
unless you indicate those you do not want us to Employer Number(s)_____________________
N/A
contact. Reason____________________________
N/A

References: Give below the names of three persons not related to you, whom you have known at
least one year.
Years
Name Address Business
Acquainted
1.
Dedra Harris 408 8th Street N, Northwood, Ia 50459 Court House 7+ years
2.
Tracy Hett Manly , Iowa Court Reporter 7+years
3.
Marlene Miller Stony Way, Mason City Iowa Homekeeper 2+ years

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Printable Job Application

The information provided in this Application for Employment is true, correct and complete. If
employed, any misstatements or omissions of fact on this application may result in my dismissal.
I understand that acceptance of an offer of employment does not create a contractual obligation
upon the employer to continue to employ me in the future.
If you decide to engage an investigative consumer reporting agency to report on my credit and
personal history, I authorize you to do so.
If a report is obtained you must provide, at my request, the name and address of the agency so I
may obtain from them the nature and substance of the information contained in the report.

___________________
1/12/18 _________________________________
Date Signature

Please complete and mail or fax a copy of this form to:

Environmental Recycling
Attn: Human Resources
PO Box 167, Bowling Green, Ohio 43402
Phone (419) 354-6110
Fax (419) 354-5110

http://www.envrecycle.com/

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