Form 324-690 - Application For Employment - Goodwill Industries Page 2

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List Employment & Business Experience (Include Volunteer, Intern, Summer, or Prior U.S. Military). Information

must be accurate, complete full and part-time records, beginning with current or most recent employer.

_____________________________________

___________________________

Current or Most Recent Employer

Phone No.

________________________________________________________________________________________

Address

______________________

______________________________

Dates:

From

Supervisor

_________________________________________________________________________________________

Duties

________________________________________________________________________________

Reason For Leaving

_______________________________________________

___________________________

Former Employer

Phone No.

________________________________________________________________________________________

Address

______________________

______________________________

Dates:

From

Supervisor

_________________________________________________________________________________________

Duties

________________________________________________________________________________

Reason For Leaving

_______________________________________________

___________________________

Former Employer

Phone No.

________________________________________________________________________________________

Address

______________________

______________________________

Dates:

From

Supervisor

_________________________________________________________________________________________

Duties

________________________________________________________________________________

Reason For Leaving

_______________________________________________

___________________________

Former Employer

Phone No.

________________________________________________________________________________________

Address

______________________

______________________________

Dates:

From

Supervisor

_________________________________________________________________________________________

Duties

________________________________________________________________________________

Reason For Leaving

The information I have provided on this application is accurate to the best of my knowledge and subject to validation by

Goodwill Industries of Northeast Iowa, Inc.

Employment with Goodwill Industries of Northeast Iowa, Inc. will be subject to successful completion of an interview

including A DRUG SCREEN and criminal background check, when required.

Employment with Goodwill Industries of Northeast Iowa, Inc. is for no stated period of time or duration and Goodwill

Industries of Northeast Iowa, Inc. or the employee may terminate the employment whenever either deems it best. This includes

termination of employment due to information obtained during screening, after a job offer has been made.

I understand that any false information, omissions or misrepresentations of facts called for in this application may result in

rejection of my application or discharge at any time during my employment.

____________________________________________________________________________________________

Signature of Applicant

Date of Signature

Thank you for completing the application. You can be assured that our review of your job qualifications will be based solely on

merit and a final determination reached as quickly as possible.

PLEASE CHECK TO SEE THAT YOU HAVE ANSWERED ALL THE ABOVE QUESTIONS

Goodwill Industries of Northeast Iowa, Inc. is an Equal Opportunity Employer. We do not discriminate because of race, color, creed, religion, sex, age,

marital status, national origin, physical/mental disability, or veteran status.

Revised: 01/2004

Form 324-690

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