Today's Date: -- mm/dd/yy

Please provide the following contact information:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone	- -
E-mail

Have you ever applied for employment or been employed by this company?
No
Yes

IF YES, Where and When:

Position Applied For.

Have you been convicted of a felony within the last 7 years?
No
Yes

IF YES, Explain felony conviction:



Are you legally eligible for employment in the U.S.
Yes
No


Wage Expected:



Age if under 18:



Will you work overtime or shift work?
Yes
No


Date Available:
-- mm/dd/yy



Name and address of High School:

Years Completed:



Did You Graduate:
Yes
No

Degree Or Diploma:
Degree
Diploma

Name and Address of College:

Years Completed:


Did you Graduate:
Yes
No

College Degree or Diploma:
Degree
Diploma


Vocational / Trade Or Apprentice Courses:

Most Recent Employer:

Employer
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone

Your Job Title:


Supervisor's Name:


Employed from (Start Date) to ( Quite Date):


Are you currently working for this employer?
Yes
No

If YES, May we contact:
Yes
No

List All Your Duties:


Salary (per Week or Month or Year):


Reason(s) For Leaving job #1:

Second Most Recent Employer:

Employer
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone

Your Job Title:


Supervisor's Name:


Employed From (Start Date to Quite Date):


List Your Duties For Second Employer:


Salary (per Week or Month or Year):


Reason(s) For Leaving Job #2:

Third Most Recent Employer:

Employer
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone

Job Title:


Supervisors Name:


Employed From (Start Date to Quite Date):


Salary per (Week or Month or Year):


List of Duties for Third most Recent Employer:


Reason(s) For Leaving Job #3:

REFERENCE #1: List person familiar with your work record and / or your work abilities. ( Do not include relatives)

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone

Years Known:


REFERENCE#2: List person familiar with your work record and /or abilities. ( Do not include relative)

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone

Years Known:





Do you hold a journeyman electrician license or any other electrician license with any state, county or municipality?
No
Yes

If YES, Please list the license Number(s), Date(s) of License(s) and location of:




Are you willing to take a drug test if required as part of your application?
Yes
No


If a favorable hiring decision is made, will you submit to a medical examination and /or answer a medical questionnaire ( after a hiring decision is made)?
Yes
No


Have you been given a job description or had the requirements of the job explained to you?
Yes
No


Do you understand the job requirements:
Yes
No


Can you perform the requirements of this job with or without reasonable accommodation?
Yes
No


Have you had safety training for electrical work?
Yes
No