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Application for Employment

Page 1 of 14

Personal Information

Please complete all required fields!

Last Name

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First Name

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Middle Name

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Email Address

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Street Address

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City

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State

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Zip Code

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Home Phone

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Business Phone

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Have you ever applied for employment with us?

Yes

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If yes, Month and Year:

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Previous Application Location

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Are you presently employed?

Yes

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Apart from absence for religious observance, are you available for full-time work?

Yes

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If not, what hours can you work?

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Will you work overtime if asked?

Yes

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Are you legally eligible for employment in the U.S.?

Yes

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When will you be available to work?

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Position

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Are you currently on lay-off status and subject to recall?

Yes

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How did you learn of our organization?

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College

College Name / Location of School

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Number of Years Completed

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Did you graduate?

Yes

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College Degree or Majors

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High School

High School Name / Location of School

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Number of Years Completed

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Did you graduate?

Yes

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High School Degree or Majors

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Technical School

Technical School Name / Location of School

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Number of Years Completed

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Did you graduate?

Yes

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Technical Degree or Majors

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Other

Other School Name / Location of School

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Number of Years Completed

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Did you graduate?

Yes

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Other Degree or Majors

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Are you presently in the Reserves or National Guard?

Yes

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Have you served in the Military?

Yes

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Describe your duties and any special training.

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What was your previous address?

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How long at your previous address?

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Are you over 18 years of age?

Yes

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How long at present address?

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Have you ever been bonded?

Yes

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If yes, with which employers?

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Have you ever been convicted of a felony?

Yes

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If yes, describe in full:

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State names of relatives and friends working for us other than your spouse.

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Reference One

Name

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Address

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Phone Number

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Reference Two

Name

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Address

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Phone Number

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Reference Three

Name

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Address

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Phone Number

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Reference Other

Name

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Address

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Phone Number

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Membership in Professional or Civic Organizations
(Exclude those which may disclose your race, color, religion, or natural origin)

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Company Name

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Address

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Name of Supervisor

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State Job Title and Description

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Telephone

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Employed From (Month/Year)

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Employed To (Month/Year)

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Hourly Rate / Salary Start

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Hourly Rate / Salary End

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Reason for Leaving

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Company Name

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Address

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Name of Supervisor

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State Job Title and Description

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Telephone

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Employed From (Month/Year)

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Employed To (Month/Year)

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Hourly Rate / Salary Start

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Hourly Rate / Salary End

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Reason for Leaving

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Company Name

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Address

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Name of Supervisor

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State Job Title and Description

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Telephone

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Employed From (Month/Year)

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Employed To (Month/Year)

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Hourly Rate / Salary Start

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Hourly Rate / Salary End

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Reason for Leaving

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Company Name

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Address

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Name of Supervisor

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State Job Title and Description

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Telephone

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Employed From (Month/Year)

Invalid Input

Employed To (Month/Year)

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Hourly Rate / Salary Start

Invalid Input

Hourly Rate / Salary End

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Reason for Leaving

Invalid Input

Company Name

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Address

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Name of Supervisor

Invalid Input

State Job Title and Description

Invalid Input

Telephone

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Employed From (Month/Year)

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Employed To (Month/Year)

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Hourly Rate / Salary Start

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Hourly Rate / Salary End

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Reason for Leaving

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We may contact the employers listed above unless you indicate those you do not want us to contact.
Do not contact the following:

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** PLEASE NOTE: COMPLETION OF THIS SECTION IS VOLUNTARY **

It is the policy of this company to offer equal opportunity with regard to all items and conditions of employment. The company complies with federal and state laws prohibiting discrimination on the basis of race, color, religion, creed, national origin, disability, veteran status, age, or any other protected characteristic. Certain government contractors have obligations to collect statistical data. This form is to meet that obligation and is strictly voluntary and will not be a part of the personnel file or will not be used for employment decision-making.

TO BE COMPLETED BY APPLICANT ON A VOLUNTARY BASIS, NOT FOR INTERVIEW PURPOSES. FILE SEPARATELY FROM APPLICATION.

In an effort to comply with requirements regarding government record keeping, reporting, and other legal obligations, which may apply, we request that you complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Applicant Information

Sex

Male

Female

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Referral Source

Government Employment Agency

Private Employment Agency

Current Employee

Walk-in

School

Relative

Other

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Advertisement located in

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Other referral source

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Person who referred you, if applicable

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Please select one of the following Equal Opportunity Identification groups

Hispanic

Asian / Pacific Islander

American Indian / Alaskan Native

White (Not of Hispanic Origin)

Black (Not of Hispanic Origin)

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The information provided in the Application for Employment is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in dismissal.

I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future.

If you decide to engage an investigative consumer-reporting agency to report on my credit and personal history, I authorize you to do so. If a report is obtained you must provide, at my request, the name and address of the agency so I may obtain from them the nature and substance of information contained in the report.

LMI recognizes its rights to establish rules and regulation covering the conduct of its employees. This includes the right to hire, to discharge for cause, to promote, to demote, to reassign workstations, to assign duties outside the assigned workstations and to apply disciplinary action.

Signature Date *

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Signature *

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