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Keepsake Companions

Employment Application


Applicant Information
Full Name:

Date:
Last First M.I.
Address:
Street Address Apartment/Unit #
City State ZIP Code
Phone:    E-mail Address:
Date Available: Social Security No.: Desired Salary: $
Position Applied for:
Are you a citizen of the United States? YES
NO
If no, are you authorized to work in the U.S.? YES      NO
     
Have you ever worked for this company? YES
NO
If yes, when?
Have you ever been convicted of a felony? YES
NO

If yes, explain:

 

Education
High School: Address:
From:

To:

 Did you graduate? YES
NO
College: Address:
From:

To:

 Did you graduate? YES
NO
Degree:
Other: Address:
From:

To:

 Did you graduate? YES
NO
Degree:

References
Please list three professional references.
Full Name: Relationship:
Company: Phone:
Address:
Full Name: Relationship:
Company: Phone:
Address:
Full Name: Relationship:
Company: Phone:
Address:

Previous Employment
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
From:  To: Reason for Leaving:
May we contact your previous supervisor for a reference? YES     NO
   
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
From:  To: Reason for Leaving:
May we contact your previous supervisor for a reference? YES     NO
   
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
From:  To: Reason for Leaving:
May we contact your previous supervisor for a reference? YES     NO
   

Military Service
Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:

Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

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