PLEASE PRINT
Prospective employees will receive consideration without
discrimination because of race, color, sex, age, religion, national
origin, or disability status.
NAME: LAST FIRST MIDDLE DATE:
ADDRESS: STREET SOCIAL SECURITY NUMBER
CITY STATE ZIP PHONE
E-MAIL CELLPHONE
POSITION DESIRED MINIMUM SALARY YOU WILL ACCEPT DATE YOU CAN START WORK
$ Per
SHIFT PREFERENCE TYPE OF EMPLOYMENT DESIRED CAN YOU CHANGE YOUR WORK HOURS/DAYS?
YES NO
DAY SWING GRAVE ANY FULL TIME PART TIME ON-CALL WILL YOU WORK OVERTIME IF ASKED?
YES NO
HOW DID YOU LEARN OF THIS OPENING? HAVE YOU EVER BEEN EMPLOYED HERE?
IF YES, GIVE DATES:
PREVIOUS EMPLOYMENT: ENTER LAST FOUR JOBS HELD, MOST RECENT FIRST
(Please complete in detail.)
EMPLOYER JOB TITLE AND DEPARTMENT START END
MONTH YEAR MONTH YEAR
EMPLOYER ADDRESS DUTIES START RATE END RATE
$ Per $ Per
REASON FOR LEAVING
TELEPHONE #
EMPLOYER JOB TITLE AND DEPARTMENT START END
MONTH YEAR MONTH YEAR
EMPLOYER ADDRESS DUTIES START RATE END RATE
$ Per $ Per
REASON FOR LEAVING
TELEPHONE #
EMPLOYER JOB TITLE AND DEPARTMENT START END
MONTH YEAR MONTH YEAR
EMPLOYER ADDRESS DUTIES START RATE END RATE
$ Per $ Per
REASON FOR LEAVING
TELEPHONE #
EMPLOYER JOB TITLE AND DEPARTMENT START END
MONTH YEAR MONTH YEAR
EMPLOYER ADDRESS DUTIES START RATE END RATE
$ Per $ Per
REASON FOR LEAVING
TELEPHONE #
We may contact the employers listed above unless you DO NOT CONTACT
indicate those you do not want us to contact. Employer ____________ Reason _________________
F130118A Rev 06 12/10
# of Years Did You Grade Pt. Major Subjects
EDUCATION NAME & LOCATION OF SCHOOL
Attended Graduate? Average Degrees Received
HIGH SCHOOL
COLLEGE
GRADUATE SCHOOL
TRADE, BUSINESS OR
CORRESPONDENCE
SCHOOL
SUBJECT OF SPECIAL STUDY OR RESEARCH
Have you ever had any job related training in the United States military? YES NO
If Yes, please describe ______________________________________________________________
_________________________________________________________________________________
Can you legally work in the United States? YES NO
Proof of citizenship or immigration status will be required upon employment.
I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an
employment decision
I understand that neither this document nor any offer of employment from the company constitute an employment
contract unless a specific document to that effect is executed by the employer and employee in writing. This application
is current for 90 days only. At the conclusion of this time, if the applicant has not heard from the Employer and still
wishes to be considered for employment, it will be necessary to fill out a new application
In the event of employment, I understand that false or misleading information given in my application or interview may
result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
Signature of Applicant Date
PANTRONIX USE ONLY
REMARKS
HIRED Yes No
Department Start Date Position Beginning Pay Rate Supervisor Corporate Approval
$ Per
F130118A Rev 06 12/10
