Gcsh Application

CERTIFICATION PLEASE READ CAREFULLY BEFORE SIGNING •

I certify that the information contained in this application is true and correct. I understand that any false or misleading statements or omissions regarding this application, whenever discovered, are grounds for disqualification for further consideration or for dismissal from employment.

•

If employed, I agree to conform to the guidelines and policies of Goodwill Contract Services Hawaii, Inc. I understand that MY EMPLOYMENT IS AT-WILL AND CAN BE TERMINATED AT ANY TIME AND FOR ANY REASON WITH OR WITHOUT ADVANCE NOTICE.

•

I understand and agree that only the President/CEO of Goodwill Contract Services Hawaii, Inc. has any authority to enter into any agreement to employ me for any specified period of time or to modify terms and conditions of my employment. I agree that such an agreement must be in writing and signed by the President/CEO, and I will not rely upon anything else.

•

I understand and agree that Goodwill Contract Services Hawaii, Inc. may make a full and complete investigation of my personal or employment history, and authorize any former employer, person, firm, corporation, school, government agency, or other entity to provide the Company with any information (including fact or opinion) they may have regarding me. In consideration of the Company's review of this application, I release the Company and all providers of any information from any liability which may arise from a violation of the Fair Credit Reporting Act (“FCRA”). I understand and agree that if offered employment by the Company, any such employment offer shall be dependent upon the receipt of satisfactory references as determined by the Company. If employed by the Company, I further authorize the Company to provide truthful information (including fact or opinion) regarding my employment to any potential or future employer and release and waive any claims against the Company for truthfully communicating any such information to a potential or future employer.

•

I understand and agree that I may be required to submit to drug testing and complete post-offer medical examination as part of my application for employment. I also understand and agree that I may be required to submit to a complete medical examination during my employment with the Company, provided that such examination is jobrelated and consistent with business necessity. The cost of such examination will be paid by the Company. I authorize the physician conducting the examination and any laboratory testing any specimen obtained by the physician or collection site to disclose the results of the examination and the laboratory test to the Company in accordance with state and / or federal laws. The Company will keep such results confidential and disclose the results only to person(s) who need to know or where required by law. Also, I agree to fully cooperate and provide the Company with any additional consent(s) and / or release(s) as required by the Company to investigate my employment application.

2610 Kilihau Street Honolulu, Hawaii 96819 Phone: (808) 836-0313 Fax: (808) 839-7322 INSTRUCTIONS: Thank you for your interest in our company. Please complete all portions of this employment application to be considered for employment. If you require accommodation during the employment application process, including assistance in the completion of this employment application, please let us know. We are an equal opportunity employer. We do not discriminate on the basis of age, race, sex, religion, color, national origin, ancestry, marital status, disability, sexual orientation, arrest and court record or any other protected category recognized by state and federal laws. This employment application is valid for a three-month period after submission to the Company and only for the desired position.

PERSONAL INFORMATION LAST NAME

•

•

Goodwill Contract Services Hawaii, Inc. may inquire into and consider any criminal conviction record that you may have after a conditional offer of employment is made to you. The company may withdraw a conditional employment offer if you have a criminal conviction record which bears a rational relationship to the duties and responsibilities of the position for which you are applying. Any criminal conviction record that is more that 10 years old or that involves Family Court matters will not be considered.

M.I.

PRESENT ADDRESS

CITY, STATE, ZIP

DO YOU MEET THE MINIMUM AGE REQUIREMENT SET BY LAW FOR THE DESIRED POSITION?

PHONE

YES

SOCIAL SECURITY NO.

CAN YOU, AFTER EMPLOYMENT, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES?

NO

YES

NO

* NOTE: If offered employment you will be required to submit documentation required by IRCA.

DESIRED EMPLOYMENT DESIRED POSITION*

DATE YOU CAN START

ARE YOU EMPLOYED NOW?

HAVE YOU BEEN PROVIDED WITH THE JOB DESCRIPTION OF THE DESIRED POSITION?

YES

SALARY DESIRED

NO

YES

NO

IF YOU HAVE BEEN PROVIDED WITH A JOB DESCRIPTION OF THE DESIRED POSITION, PLEASE ANSWER THE QUESTION: AFTER READING THE JOB DESCRIPTION, CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION WITH OR WITHOUT REASONABLE ACCOMMODATION? YES

NO

HAVE YOU EVER APPLIED FOR EMPLOYMENT AT THIS COMPANY BEFORE? YES

•

FIRST NAME

WHERE?

WHEN?

NO

WHO REFERRED YOU TO THIS COMPANY? RELATIVE_______________________ STATE EMPLOYMENT OFFICE

EMPLOYMENT AGENCY COLLEGE PLACEMENT SERVICE

NEWSPAPER ADVERTISEMENT WALK IN

APART FROM RELIGION OBSERVANCES, WILL YOU BE ABLE TO WORK ALL OTHER TIMES?

YES

FRIEND OTHER

NO

*NOTE: If hired, you will be required to perform work as required by the Company.

I understand and agree that if offered employment by Goodwill Contract Services Hawaii, Inc., I may be required to disclose military services information in accordance with law, and that any such employment offer shall be dependent upon the receipt of a satisfactory military record as determined by the Company. I understand and agree that all of the foregoing terms and conditions will become part of my employment relationship with the Company if I am employed by the Company.

EDUCATION / TRAINING HIGH SCHOOL

SCHOOL NAME & LOCATION

NO. OF YEARS ATTENDED

Authorization/Signature of applicant:__________________________________________________________________

DID YOU GRADUATE?

DIPLOMA / DEGREE

Date:_______________________________ DESCRIBE COURSE OF STUDY

UNDERGRADUATE COLLEGE / UNIVERSITY

OTHER

FORMER EMPLOYERS LIST BELOW YOUR LAST FOUR EMPLOYERS, STARTING WITH THE MOST RECENT ONE FIRST. FOR EACH EMPLOYER, YOU MUST ANSWER ALL QUESTIONS. USE ADDITIONAL PAPER IF NECESSARY. NAME OF PRESENT OR LAST EMPLOYER ADDRESS

CITY

STATE

NAME OF PRESENT OR LAST EMPLOYER ADDRESS

CITY

STATE

ZIP

STARTING DATE

DATE LAST WORKED

JOB TITLE

STARTING HOURLY RATE/MO. SALARY

FINAL HOURLY RATE/MO. SALARY

MAY WE CONTACT YOUR SUPERVISOR?

NAME OF SUPERVISOR

SUPERVISOR’S TITLE

SUPERVISOR’S PHONE NUMBER

YES

NO

ZIP

STARTING DATE

DATE LAST WORKED

JOB TITLE

STARTING HOURLY RATE/MO. SALARY

FINAL HOURLY RATE/MO. SALARY

MAY WE CONTACT YOUR SUPERVISOR?

NAME OF SUPERVISOR

SUPERVISOR’S TITLE

SUPERVISOR’S PHONE NUMBER

DESCRIPTION OF WORK YES

NO REASON(S) FOR LEAVING

REFERENCES

DESCRIPTION OF WORK

GIVE THE NAMES OF THREE PERSONS YOU ARE NOT RELATED TO, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR AND WHOM WE CAN CONTACT.

REASON(S) FOR LEAVING

NAME

ADDRESS

YEARS KNOWN

PHONE NUMBER

1

NAME OF PRESENT OR LAST EMPLOYER

2 ADDRESS

CITY

STATE

ZIP 3

STARTING DATE

DATE LAST WORKED

JOB TITLE

STARTING HOURLY RATE/MO. SALARY

FINAL HOURLY RATE/MO. SALARY

MAY WE CONTACT YOUR SUPERVISOR?

NAME OF SUPERVISOR

SUPERVISOR’S TITLE

SUPERVISOR’S PHONE NUMBER

JOB SKILLS, QUALIFICATIONS AND EMPLOYMENT GAPS YES

NO

DESCRIPTION OF WORK

REASON(S) FOR LEAVING

NAME OF PRESENT OR LAST EMPLOYER ADDRESS

CITY

STATE

ZIP

STARTING DATE

DATE LAST WORKED

STARTING HOURLY RATE/MO. SALARY

FINAL HOURLY RATE/MO. SALARY

MAY WE CONTACT YOUR SUPERVISOR?

NAME OF SUPERVISOR

SUPERVISOR’S TITLE

SUPERVISOR’S PHONE NUMBER

DESCRIPTION OF WORK

REASON(S) FOR LEAVING

JOB TITLE

YES

NO

SUMMARIZE YOUR JOB SKILLS, TRAINING AND/OR STUDY THAT ARE RELEVANT FOR THE DESIRED POSITION. ALSO, EXPLAIN ANY PERIODS THAT YOU WERE NOT WORKING. USE ADDITIONAL PAPER IF NECESSARY.

FORMER EMPLOYERS LIST BELOW YOUR LAST FOUR EMPLOYERS, STARTING WITH THE MOST RECENT ONE FIRST. FOR EACH EMPLOYER, YOU MUST ANSWER ALL QUESTIONS. USE ADDITIONAL PAPER IF NECESSARY. NAME OF PRESENT OR LAST EMPLOYER ADDRESS

CITY

STATE

NAME OF PRESENT OR LAST EMPLOYER ADDRESS

CITY

STATE

ZIP

STARTING DATE

DATE LAST WORKED

JOB TITLE

STARTING HOURLY RATE/MO. SALARY

FINAL HOURLY RATE/MO. SALARY

MAY WE CONTACT YOUR SUPERVISOR?

NAME OF SUPERVISOR

SUPERVISOR’S TITLE

SUPERVISOR’S PHONE NUMBER

YES

NO

ZIP

STARTING DATE

DATE LAST WORKED

JOB TITLE

STARTING HOURLY RATE/MO. SALARY

FINAL HOURLY RATE/MO. SALARY

MAY WE CONTACT YOUR SUPERVISOR?

NAME OF SUPERVISOR

SUPERVISOR’S TITLE

SUPERVISOR’S PHONE NUMBER

DESCRIPTION OF WORK YES

NO REASON(S) FOR LEAVING

REFERENCES

DESCRIPTION OF WORK

GIVE THE NAMES OF THREE PERSONS YOU ARE NOT RELATED TO, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR AND WHOM WE CAN CONTACT.

REASON(S) FOR LEAVING

NAME

ADDRESS

YEARS KNOWN

PHONE NUMBER

1

NAME OF PRESENT OR LAST EMPLOYER

2 ADDRESS

CITY

STATE

ZIP 3

STARTING DATE

DATE LAST WORKED

JOB TITLE

STARTING HOURLY RATE/MO. SALARY

FINAL HOURLY RATE/MO. SALARY

MAY WE CONTACT YOUR SUPERVISOR?

NAME OF SUPERVISOR

SUPERVISOR’S TITLE

SUPERVISOR’S PHONE NUMBER

JOB SKILLS, QUALIFICATIONS AND EMPLOYMENT GAPS YES

NO

DESCRIPTION OF WORK

REASON(S) FOR LEAVING

NAME OF PRESENT OR LAST EMPLOYER ADDRESS

CITY

STATE

ZIP

STARTING DATE

DATE LAST WORKED

STARTING HOURLY RATE/MO. SALARY

FINAL HOURLY RATE/MO. SALARY

MAY WE CONTACT YOUR SUPERVISOR?

NAME OF SUPERVISOR

SUPERVISOR’S TITLE

SUPERVISOR’S PHONE NUMBER

DESCRIPTION OF WORK

REASON(S) FOR LEAVING

JOB TITLE

YES

NO

SUMMARIZE YOUR JOB SKILLS, TRAINING AND/OR STUDY THAT ARE RELEVANT FOR THE DESIRED POSITION. ALSO, EXPLAIN ANY PERIODS THAT YOU WERE NOT WORKING. USE ADDITIONAL PAPER IF NECESSARY.

CERTIFICATION PLEASE READ CAREFULLY BEFORE SIGNING •

I certify that the information contained in this application is true and correct. I understand that any false or misleading statements or omissions regarding this application, whenever discovered, are grounds for disqualification for further consideration or for dismissal from employment.

•

If employed, I agree to conform to the guidelines and policies of Goodwill Contract Services Hawaii, Inc. I understand that MY EMPLOYMENT IS AT-WILL AND CAN BE TERMINATED AT ANY TIME AND FOR ANY REASON WITH OR WITHOUT ADVANCE NOTICE.

•

I understand and agree that only the President/CEO of Goodwill Contract Services Hawaii, Inc. has any authority to enter into any agreement to employ me for any specified period of time or to modify terms and conditions of my employment. I agree that such an agreement must be in writing and signed by the President/CEO, and I will not rely upon anything else.

•

I understand and agree that Goodwill Contract Services Hawaii, Inc. may make a full and complete investigation of my personal or employment history, and authorize any former employer, person, firm, corporation, school, government agency, or other entity to provide the Company with any information (including fact or opinion) they may have regarding me. In consideration of the Company's review of this application, I release the Company and all providers of any information from any liability which may arise from a violation of the Fair Credit Reporting Act (“FCRA”). I understand and agree that if offered employment by the Company, any such employment offer shall be dependent upon the receipt of satisfactory references as determined by the Company. If employed by the Company, I further authorize the Company to provide truthful information (including fact or opinion) regarding my employment to any potential or future employer and release and waive any claims against the Company for truthfully communicating any such information to a potential or future employer.

•

I understand and agree that I may be required to submit to drug testing and complete post-offer medical examination as part of my application for employment. I also understand and agree that I may be required to submit to a complete medical examination during my employment with the Company, provided that such examination is jobrelated and consistent with business necessity. The cost of such examination will be paid by the Company. I authorize the physician conducting the examination and any laboratory testing any specimen obtained by the physician or collection site to disclose the results of the examination and the laboratory test to the Company in accordance with state and / or federal laws. The Company will keep such results confidential and disclose the results only to person(s) who need to know or where required by law. Also, I agree to fully cooperate and provide the Company with any additional consent(s) and / or release(s) as required by the Company to investigate my employment application.

2610 Kilihau Street Honolulu, Hawaii 96819 Phone: (808) 836-0313 Fax: (808) 839-7322 INSTRUCTIONS: Thank you for your interest in our company. Please complete all portions of this employment application to be considered for employment. If you require accommodation during the employment application process, including assistance in the completion of this employment application, please let us know. We are an equal opportunity employer. We do not discriminate on the basis of age, race, sex, religion, color, national origin, ancestry, marital status, disability, sexual orientation, arrest and court record or any other protected category recognized by state and federal laws. This employment application is valid for a three-month period after submission to the Company and only for the desired position.

PERSONAL INFORMATION LAST NAME

•

•

Goodwill Contract Services Hawaii, Inc. may inquire into and consider any criminal conviction record that you may have after a conditional offer of employment is made to you. The company may withdraw a conditional employment offer if you have a criminal conviction record which bears a rational relationship to the duties and responsibilities of the position for which you are applying. Any criminal conviction record that is more that 10 years old or that involves Family Court matters will not be considered.

M.I.

PRESENT ADDRESS

CITY, STATE, ZIP

DO YOU MEET THE MINIMUM AGE REQUIREMENT SET BY LAW FOR THE DESIRED POSITION?

PHONE

YES

SOCIAL SECURITY NO.

CAN YOU, AFTER EMPLOYMENT, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES?

NO

YES

NO

* NOTE: If offered employment you will be required to submit documentation required by IRCA.

DESIRED EMPLOYMENT DESIRED POSITION*

DATE YOU CAN START

ARE YOU EMPLOYED NOW?

HAVE YOU BEEN PROVIDED WITH THE JOB DESCRIPTION OF THE DESIRED POSITION?

YES

SALARY DESIRED

NO

YES

NO

IF YOU HAVE BEEN PROVIDED WITH A JOB DESCRIPTION OF THE DESIRED POSITION, PLEASE ANSWER THE QUESTION: AFTER READING THE JOB DESCRIPTION, CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION WITH OR WITHOUT REASONABLE ACCOMMODATION? YES

NO

HAVE YOU EVER APPLIED FOR EMPLOYMENT AT THIS COMPANY BEFORE? YES

•

FIRST NAME

WHERE?

WHEN?

NO

WHO REFERRED YOU TO THIS COMPANY? RELATIVE_______________________ STATE EMPLOYMENT OFFICE

EMPLOYMENT AGENCY COLLEGE PLACEMENT SERVICE

NEWSPAPER ADVERTISEMENT WALK IN

APART FROM RELIGION OBSERVANCES, WILL YOU BE ABLE TO WORK ALL OTHER TIMES?

YES

FRIEND OTHER

NO

*NOTE: If hired, you will be required to perform work as required by the Company.

I understand and agree that if offered employment by Goodwill Contract Services Hawaii, Inc., I may be required to disclose military services information in accordance with law, and that any such employment offer shall be dependent upon the receipt of a satisfactory military record as determined by the Company. I understand and agree that all of the foregoing terms and conditions will become part of my employment relationship with the Company if I am employed by the Company.

EDUCATION / TRAINING HIGH SCHOOL

SCHOOL NAME & LOCATION

NO. OF YEARS ATTENDED

Authorization/Signature of applicant:__________________________________________________________________

DID YOU GRADUATE?

DIPLOMA / DEGREE

Date:_______________________________ DESCRIBE COURSE OF STUDY

UNDERGRADUATE COLLEGE / UNIVERSITY

OTHER

Goodwill Industries of Hawaii, Inc./Goodwill Contract Services Hawaii, Inc. AFFIRMATIVE ACTION SELF-IDENTIFICATION SURVEY Goodwill is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite applicants/employees to voluntarily selfidentify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those which require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Name:________________________________________

Date:_____/_____/_____

Job Title:______________________________________

Department:_____________________

SEX:

____Male

_____Female

RACE:

(Check all categories that apply) _____ Caucasian (White, not Hispanic or Latino): A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. _____ Black or African American (Not Hispanic or Latino): A person having origins in any of the Black racial groups of Africa. _____ Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race. _____ American Indian or Alaskan Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America), and maintain tribal affiliation or community attachment. _____ Asian (Not Hispanic of Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillipine Islands, Thailand, and Vietnam. _____ Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. ______ Hawaii ______ Guam ______ Samoa ______ Micronesia: Name of Island__________________________________________ ______ Other Pacific Islander _____ Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the above races except Hispanic or Latino.

Goodwill Industries of Hawaii, Inc./Goodwill Contract Services Hawaii, Inc. AFFIRMATIVE ACTION SELF-IDENTIFICATION SURVEY

DISABILITY:

(Check if applicable) _____ Yes (Disabled): Any person who (1)

Has a physical or mental impairment which substantially limits one or more of such person’s major life activities,

(2)

Has a record of such impairment, or

(3)

Is regarded as having such an impairment.

VETERANS STATUS: (Check if applicable) _____ Vietnam Era Veteran:

A person who

(1)

Served on active duty for a period of more than 180 days, any part of which Occurred between August 5, 1964 and May 7, 1975, and was discharged or released with other than a dishonorable discharge, or

(2)

Was discharged or released from active duty for a service-connected disability.

_____ Veteran: A person who Served on active duty during a war or in a campaign or expedition for which a campaign badge was authorized.

Goodwill Industries of Hawaii, Inc./GCSH 2610 Kilihau Street, Honolulu, HI 96819 Telephone: (808) 836-0313 Fax: (808) 839-7322

EMPLOYMENT VERIFICATION AND AUTHORIZATION RELEASE To:

Employer:___________________________________________________________________ Address:____________________________________________________________________ Telephone: (

)______________________________ Fax: ( )______________________

I have applied for employment with Goodwill Industries of Hawaii, Inc. I authorize you to release all information below including any employment record, character, work habits, attendance and the reason for my leaving your employment in the section below. I release you and your agents from any and all claims arising from your response to this information. The following data may help in identifying my record. Thank you for your assistance in this matter. Applicant name: ____________________________

SS#:_____________________________

Position held: ______________________________

Dept: ____________________________

Immediate Supervisor:_______________________

Salary:_______________ Per:________

Dates of employment:

From: ___/___/___

To:___/___/___

Applicants Signature:___________________________ Date: ___/___/___ TO BE COMPLETED BY PREVIOUS EMPLOYER Position held: ______________________________

Dept:____________________________

Rate/Salary:________________________________

Per Hour/ Week/ Month/ Year

Dates of employment:

From: ___/___/___

Discharged:____

To:___/___/___

Reasigned:____

Laid off: ____

Applicant’s reason for leaving:________________________________________________________ Would you rehire the applicant? Yes: ___ No:___ Please rate the applicant’s performance in the following areas: What are the applicant’s strong points?______________________________________________________ What are the applicant’s weak points?_______________________________________________________ Above Average

Average

Below Average

Comments

Attendance Cooperation Job Knowledge Initiative Productivity Reliability Quality of Work Print Name:________________________________

Title:____________________________

Signature:_________________________________

Date: ___/___/___

Goodwill Industries of Hawaii, Inc./GCSH 2610 Kilihau Street, Honolulu, HI 96819 Telephone: (808) 836-0313 Fax: (808) 839-7322

EMPLOYMENT VERIFICATION AND AUTHORIZATION RELEASE To:

Employer:___________________________________________________________________ Address:____________________________________________________________________ Telephone: (

)______________________________ Fax: ( )______________________

I have applied for employment with Goodwill Industries of Hawaii, Inc. I authorize you to release all information below including any employment record, character, work habits, attendance and the reason for my leaving your employment in the section below. I release you and your agents from any and all claims arising from your response to this information. The following data may help in identifying my record. Thank you for your assistance in this matter. Applicant name: ____________________________

SS#:_____________________________

Position held: ______________________________

Dept: ____________________________

Immediate Supervisor:_______________________

Salary:_______________ Per:________

Dates of employment:

From: ___/___/___

To:___/___/___

Applicants Signature:___________________________ Date: ___/___/___ TO BE COMPLETED BY PREVIOUS EMPLOYER Position held: ______________________________

Dept:____________________________

Rate/Salary:________________________________

Per Hour/ Week/ Month/ Year

Dates of employment:

From: ___/___/___

Discharged:____

To:___/___/___

Reasigned:____

Laid off: ____

Applicant’s reason for leaving:________________________________________________________ Would you rehire the applicant? Yes: ___ No:___ Please rate the applicant’s performance in the following areas: What are the applicant’s strong points?______________________________________________________ What are the applicant’s weak points?_______________________________________________________ Above Average

Average

Below Average

Comments

Attendance Cooperation Job Knowledge Initiative Productivity Reliability Quality of Work Print Name:________________________________ Title:____________________________Signature:_________________________________ Date: ___/___/___

Goodwill Industries of Hawaii, Inc./GCSH 2610 Kilihau Street, Honolulu, HI 96819 Telephone: (808) 836-0313 Fax: (808) 839-7322

EMPLOYMENT VERIFICATION AND AUTHORIZATION RELEASE To:

Employer:___________________________________________________________________ Address:____________________________________________________________________ Telephone: (

)______________________________ Fax: ( )______________________

I have applied for employment with Goodwill Industries of Hawaii, Inc. I authorize you to release all information below including any employment record, character, work habits, attendance and the reason for my leaving your employment in the section below. I release you and your agents from any and all claims arising from your response to this information. The following data may help in identifying my record. Thank you for your assistance in this matter. Applicant name: ____________________________

SS#:_____________________________

Position held: ______________________________

Dept: ____________________________

Immediate Supervisor:_______________________

Salary:_______________ Per:________

Dates of employment:

From: ___/___/___

To:___/___/___

Applicants Signature:___________________________ Date: ___/___/___ TO BE COMPLETED BY PREVIOUS EMPLOYER Position held: ______________________________

Dept:____________________________

Rate/Salary:________________________________

Per Hour/ Week/ Month/ Year

Dates of employment:

From: ___/___/___

Discharged:____

To:___/___/___

Reasigned:____

Laid off: ____

Applicant’s reason for leaving:________________________________________________________ Would you rehire the applicant? Yes: ___ No:___ Please rate the applicant’s performance in the following areas: What are the applicant’s strong points?______________________________________________________ What are the applicant’s weak points?_______________________________________________________ Above Average

Average

Below Average

Comments

Attendance Cooperation Job Knowledge Initiative Productivity Reliability Quality of Work Print Name:________________________________

Title:____________________________

Signature:_________________________________

Date: ___/___/___