Lomeda Services

Name (First, M.I., Last)

Maiden Name

Last four of Social Security Number

Mailing Address

City, State, and Zip Code

Home Phone

Cell Phone

E mail Address

example@example.com

May we use email to contact you

YesNo

Referred by

Additional Information:

These questions must be answered in order to be considered for employment.

Have you been an employee of this organization in the past?

YesNo

I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States

YesNo

Have you ever been convicted of, or entered a plea of guilty, no contest, or had a withheld judgment to a felony?** If Yes, please explain

Education

(Schools attended or special training received)

(List current or most recent first)

School

From

To

Highest grade completed?

Location

Type of degree or diploma

School

From

To

Did you graduate?

Location

Type of degree or diploma

School

From

To

Did you graduate?

Location

Type of degree or diploma

All applicants must have a valid driver's license with less than 6 points, current insurance and a high school diploma or GED to be eligible for employment.

Work History

(List present or most recent job first)

Job Title

From

To

Hrs/Week

Employer

Address

Phone

Supervisor

Reason for leaving?

May we contact this employer

YesNo

Job Title

From

To

Hrs/Week

Employer

Address

Phone

Supervisor

Reason for leaving?

May we contact this employer

YesNo

Job Title

From

To

Hrs/Week

Employer

Address

Phone

Supervisor

Reason for leaving?

May we contact this employer

YesNo

Signature

Date

I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should an investigation disclose untruthful or misleading answers, my application may be rejected, my name removed from consideration, or my employment with this company terminated.

PLEASE LIST YOUR AVAILABILITY