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.
Email*
example@example.com
Date Available*

MonthDayYear
Desired Salary*
Position Applying for*
Are you a citizen of the United States?*

YesNo
If no, are you authorized to work in the U.S. ?*

YesNo
Have you ever worked for this company?*

YesNo
If so, when?

MonthDayYear
Have you ever been convicted of a felony?*

YesNo
If yes, explain
Education
High School*
Address*
Street Address, City, State, Zip
From*

MonthDayYear
To*

MonthDayYear
Did you graduate?*

YesNo
Diploma
College
Address
Street Address, City, State, Zip
From

MonthDayYear
To

MonthDayYear
Did you graduate?

YesNo
Degree
Other
Address
Street Address, City, State, Zip
From

MonthDayYear
To

MonthDayYear
Did you graduate?

YesNo
Degree
References

Please list three professional references.
Full Name*
First & Last Name
Relationship*
Company*
Phone Number
Please enter a valid phone number.
Address*
Street Address, City, State, Zip
Full Name*
First & Last Name
Relationship*
Company*
Phone Number
Please enter a valid phone number.
Address*
Street Address, City, State, Zip
Full Name*
First & Last Name
Relationship*
Company*
Phone Number
Please enter a valid phone number.
Address*
Street Address, City, State, Zip
Previous Employment

List the most recent as first
Company
Phone Number
Please enter a valid phone number.
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?

YesNo
Company
Phone Number
Please enter a valid phone number.
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?

YesNo
Company
Phone Number
Please enter a valid phone number.
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?

YesNo
Experience
Check all you have experience with:

FaucetsVanity InstallationToiletsWater HeatersTankless Water HeatersWater SoftenersWater LinesWell PumpsClogged DrainsClogged SewerGarbage DisposalWater filtersWater Conditioning SystemGas Lines
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