# Employment Form Submission

## Personal Information

First Name: $firstName
Last Name: $lastName
Initial: $
Social Security Number: $social
Present Address: $personalAddress
City: $personalCity
State: $personalState
Zip Code: $personalZip
Day-time Phone: $phoneDay
Evening Phone: $phoneNight

## Work Preference

Date Available: $dateAvailable
Kind of Work Desired: $typeWork
Salary or Pay You Expect: $salary
List job benefits, other than wages, you expect or want in order of importance:
$jobBenefits
Describe your prior experience in the kind of work you want:
$relatedExperience
Describe any job related formal schooling or training:
$formalTraining
List any job related licenses or certificates you may have:
$relatedCertificates
List any job related special skills you may have (typing, machine operation, etc.):
$relatedSkills

## Availability For Work

Which type of employment are you seeking: $typeEmploy
Shifts you are willing to work: $shifts
Will you work daily overtime on occasion if necessary?: $overtime
Will you work extra days in the week if necessary?: $extraDays

## Present Employment

Do you have to give advance notice to your present employer? $giveNotice

## Personal

Would you be willing to take a drug/alcohol screening exam before and after employment if requested? $drugScreen
Have you missed more than a day or two of work or school for any reason in the past five years? $missedWork
Are you a minor (under 18 years old)? $aMinor

## Prior Events

Have you ever worked for or applied for work at this company before? $workedHere
Have you ever been discharged for cause? $discharged
Have you ever been convicted of a criminal offense?: $convicted
If yes, please explain: $convictedExplain

## Grade and High School

Name of Last School: $highSchoolName
Location: $highSchoolLocation
Did you graduate? $highSchoolGraduate
Grade Point Average: $highSchoolGPA
Special Courses (typing, etc.): $highSchoolCourses
What is the last year you completed?: $highSchoolYear

## College or University

Name of School: $collegeName
Location: $collegeLocation
Years Attended: $collegeYears
Major Subject: $collegeMajor
Degree Attained: $collegeAttained
Grade Point Average: $collegeGPA

## Other (Graduate, Trade School, Correspondence School, etc)

Name of School: $otherName
Location: $otherLocation
Length of Course: $otherYears
Major Subject: $otherMajor
Was Course Completed? $otherAttained
Grade Point Average: $otherGPA

## Current / Most Recent Employer

Name of Employer: $emp1_Name
Address: $emp1_address
City: $emp1_City
State: $emp1_State
Zip: $emp1_Zip
Phone: $emp1_phone
List the jobs you held, duties performed, skills used or learned, advancements or promotions:
$emp1_about
Start Date: $emp1_startDate
End Date: $emp1_endDate
Starting Rate of Pay: $emp1_startRate
Ending Rate of Pay: $emp1_endRate
Supervisor's Name: $emp1_superName
Type of Business: $emp1_busType
What did you like about this job?
$emp1_LikeJob
What did you dislike about this job?
$emp1_DislikeJob
Why did you leave? $emp1_reasonLeave
Reference Check Contact: $emp1_reference

## Next Previous Employer

Name of Employer: $emp2_Name
Address: $emp2_address
City: $emp2_City
State: $emp2_State
Zip: $emp2_Zip
Phone: $emp2_phone
List the jobs you held, duties performed, skills used or learned, advancements or promotions:
$emp2_about
Start Date: $emp2_startDate
End Date: $emp2_endDate
Starting Rate of Pay: $emp2_startRate
Ending Rate of Pay: $emp2_endRate
Supervisor's Name: $emp2_superName
Type of Business: $emp2_busType
What did you like about this job?
$emp2_LikeJob
What did you dislike about this job?
$emp2_DislikeJob
Why did you leave? $emp2_reasonLeave
Reference Check Contact: $emp2_reference

## Next Previous Employer

Name of Employer: $emp3_Name
Address: $emp3_address
City: $emp3_City
State: $emp3_State
Zip: $emp3_Zip
Phone: $emp3_phone
List the jobs you held, duties performed, skills used or learned, advancements or promotions:
$emp3_about
Start Date: $emp3_startDate
End Date: $emp3_endDate
Starting Rate of Pay: $emp3_startRate
Ending Rate of Pay: $emp3_endRate
Supervisor's Name: $emp3_superName
Type of Business: $emp3_busType
What did you like about this job?
$emp3_LikeJob
What did you dislike about this job?
$emp3_DislikeJob
Why did you leave? $emp3_reasonLeave
Reference Check Contact: $emp3_reference

## List other positions and periods of unemployment:

$otherPositions

Do you Agree? $formAgree