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LAWS ENACTED BY THE FEDERAL GOVERNMENT AND BY MANY STATES PROHIBIT JOB DISCRIMINATION BASED UPON RACE, RELIGION, COLOR, NATIONAL ORIGIN, SEX, AGE, DISABILITY OR MARITAL STATUS, UNLESS BASED UPON A BONAFIDE OCCUPATIONAL REQUIREMENT OR OTHER EXCEPTION.

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GENERAL INFORMATION

First Name:

Middle Initial:

Last Name:

Social Security #:

Telephone Number:

Email Address:

Street Address:

City:

State:

Zip Code:

Have you lived at the above address for two or more years?

Yes

No

For what position are you applying:

Inside Sales Office/Admin Outside Sales Management Technician

Rate of pay expected per week:

Do you wish to work:

Full Time

PartTime

Were you previously employed by us?

YesNo

If yes, when?

List any family or friends working for us: (separate names with a comma)

If your application is considered favorable, on what date will you be available for work?

(mm/dd/yyyy)

Are there any other experiences, skills or qualifications which you feel would especially fit you for work with the company?

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EMERGENCY CONTACT INFORMATION

Person to be notified in case of accident or emergency:

Telephone Number:

Street Address:

City:

State:

Zip Code:

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MILITARY SERVICE RECORD

Were you in the U.S. Armed Forces?

YesNo

If yes, what branch?

Dates of duty...

From:

(mm/dd/yyyy)

To

(mm/dd/yyyy)

Rank at discharge:

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EDUCATION

High School:		Years:		Field of Study:		Graduate?	YesNo
College/University:		Years:		Field of Study:		Graduate?	YesNo
Business/Technical:		Years:		Field of Study:		Graduate?	YesNo

Please describe any other relevant training or education below:

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EMPLOYMENT HISTORY

Please list below your last three places employment beginning with your most recent. If you do not have three previous employers, please list as many as you have beginning with your most recent.

Employment #1

Employment #2

Employment #3

Have you ever been bonded?

YesNo

If yes, on what job(s)?

May we contact all of the employers listed above?

Yes

No

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OPTIONAL INFORMATION

The following information is optional and is not a required element of this application for employment.

Date of Birth:

(mm/dd/yyyy)

Sex:

MaleFemale

Height:

(inches)

Weight:

(lbs.)

Marital Status:

SingleMarriedSeparatedDivorcedWidowed

Date of Marriage:

(mm/dd/yyyy)

Number of dependents including yourself:

Number of children:

Their ages:

Does your wife/husband work?

YesNo

If yes, what kind?:

Do you own your home?

YesNo

Pay rent?

YesNo

Do you have a car available for your own use?

YesNo

If you have any physical defects, please describe:

If you have had a major illness in the past 5 years, please describe:

If you have received compensation for an injury, please describe:

If you have been convicted of a crime in the past 10 years, please describe:

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ACKNOWLEDGMENT

The facts set forth above in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of my personal history and financial and credit record through investigative or credit agencies or bureaus of your choice. Please review your application and then press the submit button below.