Employment Application

New Job Application Form
Full Name*

First NameLast Name
Date*

MonthDayYear
E-mail*
example@example.com
Phone Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #: xxx-xx-xxxx
What position are you applying for?*
What location are you applying for?*
Position Type*

Full TimePart Time
What hours are you available to work?
Available start date:*

MonthDayYear
Are you legally eligible for employment in the United States? *
Were you previously employed by us? blanks*
If so, when? blank*

Do you have reliable transportation to and from work?blank*

Our goal is to be a "smoke free" company, is this consistent with your lifestyle ?blank*
Are you willing to take a drug test?blank*
Education

Schooling

	Name and Location	Dates attended From: xx/xx To xx/xx	No of years completed	Graduation Year	Course of Study	GPA	Degree / Diploma
College
High School
Additional Schooling

Please Describe any courses / training relevant to the position for which you are applying:
What is your current employment status?*

EmployedUnemployedSelf-EmployedStudentOther
Employment History

Please provide a complete and accurate full-time and part-time employment history. Start with your present or most recent employer.
Company Name: blanks
Company Phone Number:   Area Code   Phone Number
Company Address:
Street Address   Address Line 2   City   State   Zip
Supervisor Name: blank
Job Title: blank
Job Description: blank
Employed from:   Date    To:   Date
Weekly Pay Start:   $    Weekly Pay Last:   $
Reason for leaving:   blank
Company Name: blanks
Company Phone Number:   Area Code   Phone Number
Company Address:
Street Address   Address Line 2   City   State   Zip
Supervisor Name: blank
Job Title: blank
Job Description: blank
Employed from:   Date    To:   Date
Weekly Pay Start:   $    Weekly Pay Last:   $
Reason for leaving:   blank
Company Name: blanks
Company Phone Number:   Area Code   Phone Number
Company Address:
Street Address   Address Line 2   City   State   Zip
Supervisor Name: blank
Job Title: blank
Job Description: blank
Employed from:   Date    To:   Date
Weekly Pay Start:   $    Weekly Pay Last:   $
Reason for leaving:   blank
Did you serve in the U.S. Armed forces? blanks
Branch? blank

Have you been convicted of a crime in the past 10 years, excluding misdemeanors and summary defenses, which has been annulled, expunged or sealed by court?   Type a label
If yes, describe in full:   Type a label

Do you have any relatives working for us?   Type a label

Will you be employed anywhere else while working for us? If so, please state where:   Type a label
References

Please provide at least 3 references we may contact.
Reference #1  First Name   Last Name
Number:Area Code   Phone Number

Reference #2 First Name   Last Name
Number: Area Code   Phone Number

Reference #3  First Name   Last Name
Number: Area Code   Phone Number
PLEASE READ CAREFULLY BEFORE SIGNING

I certify that the statements made on this application are true and complete and I understand that any false or misleading statements on my application or during my interview proscess are groun for dismissal. I voluntarily give the Furbay Electric Supply Company permission to investiagte my past employment and background and agree to cooperate in such investigation and release all persons and organizations supplying such information from any liability.

If hired, I agree to comply with the rules and regulations of the Compnay and understand that no representative of the company other than the President has the authority to enter into an agreement for employment with me and that any such agreement must be in writing and properly signed to be valid. I understand that I may be required to submit to a physical examination and/or drug screening.
Signature*

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Date*

MonthDayYear
Resume / CV

Cancelof

For employers use only:

	Reference Checked	Comments
1.
2.
3.

Applicant interviewed by:blanks
Date:   Date
References checked by: Type a label
Date:   Date
Applicants will be considered without regard to race, creed, color, sex, age, national orgin, handicap, or veteran status. Your application will be considered active for 60 days.
Mail to: The Furbay Electric Supply Co.

208 Schroyer Ave. SW, Canton OH 44702

Email: mfurbay@furbay.com

Fax: (330) 454 - 6816
Should be Empty:

New Job Application Form

Education

Employment History

References