[] To produce a one-piece employment application form for your company,
consider editing and printing the following four pages, copying them
onto 11" x 17" paper, and folding the paper to 8.5" x 11" size.



                       Application For Employment

                             (Please Print)

We are an equal opportunity employer, dedicated to a policy of
non-discrimination in employment on any basis including age, sex, color,
race, creed, national origin, religious persuasion, marital status,
political belief, or disability that does not prohibit performance of
essential job functions.

Date: ____________________

I. Personal Information

________________________________________________________________________
Name:      Last                     First                      Middle

________________________________________________________________________
Present Address

________________________________________________________________________
Permanent Address (if different than above)

_____________________________      _____________________________________
Social Security Number             Telephone

Federal law prohibits the employment of unauthorized aliens.  All
persons hired must submit satisfactory proof of employment authorization
and identity (valid driver's license, birth certificate, Green Card,
etc.) within three days of being hired.  Failure to submit such proof
within the required time shall result in immediate employment
termination.

Position Applied For: __________________________________________________

1. Is there any information we would need about your name or use of
another name for us to be able to check your work record?  Please
specify:

________________________________________________________________________

2. Do you have any relatives who are presently (or have formerly been)
employed by (Company)?

________________________________________________________________________

3. How were you referred to (Company)? _________________________________

4. Have you ever been convicted of a felony?  __ Yes __ No
   If yes, please explain:

________________________________________________________________________

________________________________________________________________________


II. Educational History

              School Name/Location     Years Completed    Degree/Diploma

Elem/Jr. High __________________________________________________________

High School ____________________________________________________________

College ________________________________________________________________

Tech. Training _________________________________________________________

Other __________________________________________________________________


III. Employment Record  Please include all employment for the last
five years.

1. _________________________________   _________________________________
   Company Name(Current/Most Recent Employer)    Position Held

   _________________________________   Dates Employed: _________________
   Address                                             From      To

   _________________________________   _________________________________
   Manager/Supervisor                  Telephone             Wage/Salary

   _____________________________________________________________________
   Reason For Leaving

2. _________________________________   _________________________________
   Company Name                        Position Held

   _________________________________   Dates Employed: _________________
   Address                                             From      To

   _________________________________   _________________________________
   Manager/Supervisor                  Telephone             Wage/Salary

   _____________________________________________________________________
   Reason For Leaving

3. _________________________________   _________________________________
   Company Name                        Position Held

   _________________________________   Dates Employed: _________________
   Address                                             From      To

   _________________________________   _________________________________
   Manager/Supervisor                  Telephone             Wage/Salary

   _____________________________________________________________________
   Reason For Leaving


NOTE:  Use a separate sheet to list additional employers, if necessary.
We will contact all of the employers listed on this application unless
you specifically exclude them below.  Please list any employers you do
not want us to contact and your reason for the exclusion:

___________________________________    _________________________________
(Employer's Name)                      Reason

___________________________________    _________________________________
(Employer's Name)                      Reason


IV. References  Please do not include relatives or former employers.

1. ________________________________    _________________________________
   Name                                Years Known

   ________________________________    _________________________________
   Address                             Telephone

   ________________________________
   Occupation

2. ________________________________    _________________________________
   Name                                Years Known

   ________________________________    _________________________________
   Address                             Telephone

   ________________________________
   Occupation

3. ________________________________    _________________________________
   Name                                Years Known

   ________________________________    _________________________________
   Address                             Telephone

   ________________________________
   Occupation


V. Work Availability

1. If your application receives favorable consideration, when will you
be available to begin work? ____________________________________________

2. Do you have any objection to working overtime? ( ) Yes  ( ) No

3. Can you work overtime without prior notice?    ( ) Yes  ( ) No

4. Can you work on Saturday?                      ( ) Yes  ( ) No

5. Can you work on Sunday?                        ( ) Yes  ( ) No

6. Can you travel if required by this position?   ( ) Yes  ( ) No


VI. Salary / Hourly Rate Requirements

If your application receives favorable consideration, what
salary/hourly rate would you require?

$ ____________________ per ____________________


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