Employment Application
An Equal Opportunity Employer
Name
*
First Name
Middle Name
Last Name
Suffix
Present Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Permanent Address (if different from present address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Employment Desired
Position applying for:
Are you applying for regular full-time work?
Yes
No
Are you applying for regular part-time work?
Yes
No
Are you applying for temporary work, e.g. summer or holiday work?
Yes
No
What days and hours are you available for work?
If applying for temporary work, during what period of time will you be available?
Ex: 4/15/18-9/1/18
Are you available for work on weekends?
Yes
No
Would you be available to work overtime, if necessary?
Yes
No
If hired, what date can you start work?
-
Month
-
Day
Year
Date
Personal Information
How did you hear about our company and this job opening?
Have you ever applied to or worked for Dassel's before?
Yes
No
If yes, when?
Why are you applying for work at Dassel's?
If hired, would you have a reliable means of transportation to and from work?
Yes
No
Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)
Yes
No
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
Yes
No
If no, describe the functions that cannot be performed.
(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing medical examination, and to skill and agility tests.
We may refuse to hire relatives of present employees if doing so could result in actual or potential problems in supervision, security, safety or morale, or if doing so could create conflicts of interest.
Education, Training and Experience
High School Name
High School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
High School: Number of years completed
Did you graduate high school?
Yes
No
High School Degree or Diploma
College/University Name
College/University Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
College/University: Number of years completed
Did you graduate college or university?
Yes
No
College/University Degree or Diploma
Vocational/Business School Name
Vocational/Business School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vocational/Business School: Number of years completed
Did you graduate vocational/business school?
Yes
No
Vocational/Business School Degree or Diploma
Health Care Training Name
Health Care Training Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Care Training: Number of years completed
Did you graduate with health care training?
Yes
No
Health Care Training Degree or Diploma
Do you have any other experience, training, qualifications or skills that you feel make you especially suited for work at Dassel's?
Yes
No
If yes, please explain:
Are you applying for a professional position?
Yes
No
Are you licensed/certified for the job applied for?
Yes
No
Name of license/certification
Issuing state
License/certification number
Has your license/certification ever been revoked or suspended?
Yes
No
If yes, state reason(s), date of revocation or suspension, and date of reinstatement.
Employment History
List below all present and past employment starting with your most recent employer (last five years is sufficient). You must complete this section even if attaching your resume.
Employer 1
Name of Employer
Phone Number
-
Area Code
Phone Number
Type of Business
Supervisor's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Your position and duties:
Reason for leaving:
Is this your current employer?
Yes
No
May we contact this employer for a reference?
Yes
No
Employer 2
Name of Employer
Phone Number
-
Area Code
Phone Number
Type of Business
Supervisor's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Your position and duties:
Reason for leaving:
May we contact this employer for a reference?
Yes
No
Employer 3
Name of Employer
Phone Number
-
Area Code
Phone Number
Type of Business
Supervisor's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Your position and duties:
Reason for leaving:
May we contact this employer for a reference?
Yes
No
Employer 4
Name of Employer
Phone Number
-
Area Code
Phone Number
Type of Business
Supervisor's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Your position and duties:
Reason for leaving:
May we contact this employer for a reference?
Yes
No
Employer 5
Name of Employer
Phone Number
-
Area Code
Phone Number
Type of Business
Supervisor's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Your position and duties:
Reason for leaving:
May we contact this employer for a reference?
Yes
No
References
List below three people not related to you who have knowledge of your work performance within the last three years.
Reference 1
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Number of Years Acquainted
Reference 2
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Number of Years Acquainted
Reference 3
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Number of Years Acquainted
Upload your resume (optional)
Signature
*
Print Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
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