Application For Employment
Date:______________________
____Full Time
____Part Time
___Full or Part Time
If you are applying for Part Time, what days and hours
are you available?
_________________________________________________________________________________
Your Name:________________________________Telephone
Number__________________
Current
Address__________________________City___________________Zip________
How did you learn about us?
___Advertisement
___Friend
___Walk-in
___Employment Agency
___Relative
References - List the Name, Address, and Telephone Number of three
(3) references who are not relatives or former employees.
____________________________________________________________________________
Name
Address
Phone #
____________________________________________________________________________
Name
Address
Phone #
____________________________________________________________________________
Name
Address
Phone #
Please list the extent of your Education, including
trade schools, apprenticeship programs and military experience.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Briefly explain why you want to work for our company,
and what your goals are for the future.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please Answer The Following Questions With As Much
Detail As Necessary:
1.
Are you prevented from lawfully becoming employed in this country because
Status?
________No ______Yes
2.
Have you been convicted of a felony, or are there any convictions
pending?
______No _____Yes-if Yes
give
___________________________________________________________________________
3.
Are you currently employed?
______No _____Yes
4.
If you are currently employed, may we contact your employer for
references? _____No
_____Yes
5.
On what date are you available to start work? __________________________
6.
Do you have objections to working Saturdays or Sundays if necessary?
_____No _____Yes
Employer:______________________________
Telephone Number:____________________
Supervisor: ___________________________Start
Date: ___________
Reason You
Left:__________________________________________________________________
Employer:______________________________
Telephone Number:____________________
Supervisor: ___________________________Start
Date: ___________
Reason You
Left:__________________________________________________________________
Employer:______________________________
Telephone Number:____________________
Supervisor: ___________________________Start
Date: ___________
Reason You Left:__________________________________________________________________
I certify that the facts contained in this application are true and complete to
the best of my knowledge and I understand that if employed false statements
shall be grounds for dismissal. I authorize investigation of all statements
contained and the references listed above to give you any and all information
concerning my previous employment and any pertinent information they may have,
personal or otherwise, and release all parties from all liability for any damage
that may result from furnishing same to you. I understand and agree that if
hired my employment is for no definite period and may regardless of the date of
payment of my wages and salary, be terminated at any time without any prior
notice.
Signature_____________________________
Date____________________
Please return application to:
Bailey
Family Dental
557 Cottonwood Avenue
Hartland, WI 53029
262-369-8633
EQUAL OPPORTUNITY EMPLOYER