Westbrook - The Company

Application for Employment An Equal Opportunity Employer: We receive applications and hire employees without regard to race, creed, color, sex, religion, age, national origin, marital status, physical or mental handicap, disability, veterans status, and citizenship status, or an other protected category. The receipt of this application does not mean that job openings exist and does not obligate us in any way. We appreciate your interest in our organization.

* = Field Required

Personal Information:

Last Name *	First Name *	Middle Initial
Social Security Number *	Street Address *	City *
State *	Zip *	Home or Nearest Phone *

How long have you lived at the above address? *

Previous Address *

How long did you live there? *

Are you over the age of 18? *

Yes

Are you legally eligible to work in the U.S.? *

Yes

Employment Information:

Position applying for *

Date available for work

Shift Preferences

1st

2nd

3rd

What salary or pay rate do you expect? Type of Employment

Full Time

Part Time

Temporary

What days are you available to work?

What hours are you available to work?

Have you ever applied for a job with us before? *

Yes

When? Have you ever been bonded? *

Yes

Have you ever been refused bond? *

Yes

If so, state reason and date. Have you ever been convicted of a crime other than a minor traffic violation? *

Yes

If so, explain. Do you use illegal drugs? *

Yes

Does your present employer know of your plans to change employment? *

Yes

Why do you desire to make a change? Have you ever held a position of trust (handling money or confidential material)? *

Yes

Do you have steady transportation to work? *

Yes

Have you ever been discharged or asked to resign? *

Yes

Are there any other experiences, skills or qualifications you have that specifically relate to working here? Can you perform the duties of the job for which you are applying, with or without reasonable accommodation? *

Yes

Schooling	Years Completed	Degree Rec. & Major	Name of School	Location	Did You Graduate?
Grammar/HS
Trade Bus., or Correspondence
College
Graduate

Describe any other specialized or professional training (such as business, technical or nursing school). Include study courses given through public or private employment. State whether degree or certificate received.

Prior Work Record (Start with most recent or present employer.)

Name and Address of Most Recent Employer *		Telephone No. *
Immediate Supervisor (name & position) *	Date Hired *	Starting Rate *
Your Job Title & Duties *	Date Left *	Last Rate *
Reason for leaving *

Name and Address of Most Recent Employer		Telephone No.
Immediate Supervisor (name & position)	Date Hired	Starting Rate
Your Job Title & Duties	Date Left	Last Rate
Reason for leaving

Name and Address of Most Recent Employer		Telephone No.
Immediate Supervisor (name & position)	Date Hired	Starting Rate
Your Job Title & Duties	Date Left	Last Rate
Reason for leaving

Name and Address of Most Recent Employer		Telephone No.
Immediate Supervisor (name & position)	Date Hired	Starting Rate
Your Job Title & Duties	Date Left	Last Rate
Reason for leaving

May we contact the employers listed above? * If not, indicate which No. which one(s) you do not wish us to contact References (Do not list relatives or former employers)

Name *	Address *	Phone *	Occupation *
Name *	Address *	Phone *	Occupation *
Name *	Address *	Phone *	Occupation *
Name *	Address *	Phone *	Occupation *

The facts set forth in my above application for employment are true and complete. I understand that if employed, false statements or omission of information on this application, a resume, or other applicant information provided may be considered sufficient reason for dismissal. You are hereby authorized to make any investigation of my personal history and financial and credit record through any investigative or credit bureaus of your choice. In making this application for employment, I also understand that an investigative consumer report may be made whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigative consumer report.

I authorize the use of any information in this application to verify my statements, and I authorize the past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. I understand that employment at this organization is on an "at will" basis, and includes no guarantee, contract, or promise of employment for any specific length of time.

Signature of Applicant * Date *