Employment Application Page 2
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SUMMARIZE YOUR SPECIAL SKILLS OR QUALIFICATIONS:
PREVIOUS EMPLOYMENT (Begin with most recent position):
Dates of Employment From ____/____/____ To ____/____/____
Position Held:
Company Name:
Address:
Phone: (
)
Supervisor:
Title:
Responsibilities:
Reason for Leaving:
May we contact this employer for a reference?
□ Yes
□ No
Dates of Employment From ____/____/____ To ____/____/____
Position Held:
Company Name:
Address:
Phone: (
)
Supervisor:
Title:
Responsibilities:
Reason for Leaving:
May we contact this employer for a reference?
□ Yes
□ No
Dates of Employment From ____/____/____ To ____/____/____
Position Held:
Company Name:
Address:
Phone: (
)
Supervisor:
Title:
Responsibilities:
Reason for Leaving:
May we contact this employer for a reference?
□ Yes
□ No
I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my
personal, employment, educational, financial, criminal background check, or medical history and other related matters as may be necessary for an
employment decision. I hereby release employers, schools or persons from all liability when responding to inquires in connection with my application.
In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge.
Signature of Applicant:
Date: _____/_____/_____
FOR OFFICE USE - DO NOT WRITE IN THIS SPACE
PROCESS RECORD
Applicant Hired? □ Yes
□ No
Date of Birth: _____/_____/_____ (mm/dd/year)
Date Employed:
Rate of Pay:
Title:
Name:
Phone: (
)
IN CASE OF EMERGENCY NOTIFY:
TERMINATION OF EMPLOYMENT
Date of Termination: _____/_____/_____
□ Dismissed
□ Voluntarily Quit
□ Other:
□ Termination Report Placed in File
Supervisor:
X:\PFS Forms & Applications\PFS Employment Application
rev011108
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Parent category: Business