Intended Branch Location of Employment:
_____ Bentonville, AR
_____ Boston, MA
_____ Lewes, DE
_____ Little Rock/Hope, AR
_____ Memphis, TN
_____ Nashville, TN
_____ Seaford, DE
_____ Wilkes-Barre, PA
_____ Wilmington, DE
Position Applied For:
_____ Service Technician
_____ Sales-Maintenance
_____ Sales-Project
_____ Office Personnel
Type of Employment:
___ Full-time
___ Part-time
Date of Application:
____________
PERSONAL INFORMATION
First Name: _____________
Middle Initial: _____________
Last Name: _____________
Address line 1:
________________________
Address line 2: _________________________
City: ______________
State: ____
Zip: _______
Social Security Number
: ____________
Telephone Number (home):
_______________
Telephone Number (work):
_______________
Email Address:
____________________
Are you legally entitled to work in the United States?
__ Yes
__ No
Do you have a valid driver's license?
__ Yes
__ No
Are you able to lift a minimum of 50 pounds?
(Service Technician position only)
__ Yes
__ No
EDUCATION
High School attended:
_____________________________________
Did you graduate?
__ Yes
__ No
Year graduated?
______
#1:
College or Technical School attended: ______________________________
List any certifications or certificates
received:
____________________________________________
____________________________________________
____________________________________________
EMPLOYMENT HISTORY
(please list most recent positions first)
I have no employment history.
OR
Employer #1:
Start Date: _________
End Date: _________
Employer Name: _______________________________
Address line 1: _______________________________
Address line 2: _______________________________
City: _______________
State: _____
Zip: _________
Name of immediate supervisor:
________________________________
Reason for leaving:
___________________________________________________________
___________________________________________________________
May we ask your present employer for a reference?
__ Yes
__ No
REFERENCES
(please do not list
relatives or former employers)
Reference #1:
Name: _______________________________________
Address line 1: ________________________________
Address line 2: ________________________________
City: _______________
State: _____
Zip: _________
Their occupation: ___________________________
Reference #2:
Name: _______________________________________
Address line 1: ________________________________
Address line 2: ________________________________
City: _______________
State: _____
Zip: _________
Their occupation: ___________________________
Reference #3:
Name: _______________________________________
Address line 1: ________________________________
Address line 2: ________________________________
City: _______________
State: _____
Zip: _________
Their occupation: ___________________________
OTHER INFORMATION
Please list any other information that might be helpful in evaluating your
qualifications:
________________________________________________________________
________________________________________________________________
________________________________________________________________
NOTICE: By signing below, I hereby certify
that to the best of my knowledge and belief the answers given by me to the
foregoing questions and all statements made by me in the application are
correct.
If employed, I agree that all material created and produced
whether in written, graphic or broadcasting form, all inventions, new or changes
in processes developed during my employment are the exclusive property of the
company to use and/or sell and that subsequent to my employment with this
company I will not disclose, use or reveal any confidential information related
to the company without first obtaining written consent from an officer of the
company.
I hereby apply for employment upon the basis and understanding
that such employment may be terminated at any time upon notice given to me
personally or sent to my last known address.
