Dean Leith Employment Application

Dean Leith Plumbing & Heating - Employment Application
1112 Keokuk St Lincoln, IL 62656
(217)732-8598 leithplumbing@frontier.com
Applicant Information
Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date Available

MonthDayYear
Desired Salary
Position Applying for
Are you a citizen of the United States?
If no, are you authorized to work in the U.S. ?
Have you ever worked for this company?
If so, when?

MonthDayYear
Have you ever been convicted of a felony?
If yes, explain
Education
High School
Address
Street Address, City, State, Zip
From

MonthDayYear
To

MonthDayYear
Did you graduate?
Diploma
College
Address
Street Address, City, State, Zip
From

MonthDayYear
To

MonthDayYear
Did you graduate?
Degree
Other
Address
Street Address, City, State, Zip
From

MonthDayYear
To

MonthDayYear
Did you graduate?
Degree
References

Please list three professional references.
Full Name
First & Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address, City, State, Zip
Full Name
First & Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address, City, State, Zip
Full Name
First & Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address, City, State, Zip
Previous Employment

List the most recent as first
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address, City, State, Zip
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
125 characters max
From

MonthDayYear
To

MonthDayYear
Reason for Leaving
35 characters max
May we contact your previous supervisor for a reference?
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address, City, State, Zip
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
125 characters max
From

MonthDayYear
To

MonthDayYear
Reason for Leaving
35 characters max
May we contact your previous supervisor for a reference?
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address, City, State, Zip
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
125 characters max
From

MonthDayYear
To

MonthDayYear
Reason for Leaving
35 characters max
May we contact your previous supervisor for a reference?
Experience
Check all you have experience with:
Military Service
Branch
From

MonthDayYear
To

MonthDayYear
Rank at Discharge
Type of Discharge
If other than honorable, explain.
Disclaimer & 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.

By signing below, I hereby acknowledge that my electronic signature on this document shall be considered legally binding and have the same force and effect as a handwritten signature.
e-Signature
Date

MonthDayYear
Today's Date
Should be Empty:

Applicant Information

Education

References

Previous Employment

Experience

Military Service

Disclaimer & Signature