The Name in Fasteners
211 Carter Drive, Suite B, West Chester, PA 19382 Phone: (610) 429-8266 | Fax: (610) 429-8277 www.kellyindustrial.com | www.kellyindustrialcatalog.com
Employment Application
Full Name
*
First Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
*
Applying for Position
*
Please Select
Warehouse Personnel/Delivery Driver
Warehouse Supervisor
Desired Salary
Available Start Date
-
Month
-
Day
Year
Date
Have you applied to/worked for our company before?
Yes
No
Are you over the age of 18?
*
Yes
No
Do you have any relatives or acquaintances working for our company?
Yes
No
If hired, would you have transportation to/from work?
Yes
No
If hired, are you willing to undergo a background and/or controlled substance test?
Yes
No
If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?
Yes
No
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Education, Training, & Experience
High School
School City & State
Number of years completed
Did you graduate?
Yes
No
Degree/Diploma earned
College/University
School City & State
Number of years completed
Did you graduate?
Yes
No
Degree/Diploma earned
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Employment History
Are you currently employed?
*
Yes
No
If you are currently employed, may we contact your current employer?
*
Yes
No
Company Name
Supervisor
Phone Number
Please enter a valid phone number.
Employer Address
Street Address
Street Address Line 2
City
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New Mexico
New York
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Pennsylvania
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
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Virgin Islands
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West Virginia
Wisconsin
Wyoming
State
Zip Code
Length of Employment
Include dates
Salary/Hourly Rate of Pay
Position and Duties:
Reason for leaving
May we contact this employer?
Yes
No
Company Name
Supervisor
Phone Number
Please enter a valid phone number.
Employer Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Length of Employment
Include dates
Salary/Hourly Rate of Pay
Position and Duties:
Reason for leaving
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Skills & Qualifications: Licenses, Skills, Training, & Awards
Summarize any special training, skills, licenses, and/or certificates that may assist you in performing the desired job position.
References
List below three personal references who have knowledge of your work performance in the last four years. Please include professional references only.
Name
*
First Name
Last Name
Relation
Phone Number
Please enter a valid phone number.
Number of years acquainted
Name
*
First Name
Last Name
Relation
Phone Number
Please enter a valid phone number.
Number of years acquainted
Name
*
First Name
Last Name
Relation
Phone Number
Please enter a valid phone number.
Number of years acquainted
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Certifications
All the information I have supplied in this application is true and a complete statement of facts. Any false statement or omission could result in immediate elimination of employment consideration and/or dismissal, if employed. I further authorize you to contact all my references for full information regarding my employment and release them from all liability for the information they provide. If I am employed, I agree to abide by the rules and regulations of Kelly Industrial Supply, Inc. I certify that I have fully read, understand, and accept all the terms of this application.
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