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EMPLOYMENT APPLICATION

(Equal Opportunity Employer)

GENERAL INFORMATION

NAME________________________________________ SOCIAL SECURITY NO.


Last
First
Middle Initial
ADDRESS

_______________________

____________________________________________________________________________
Street

TELEPHONE NO.

City

_____________________________

WORK

______________________________

EMAIL

HOME
CELL

POSITION APPLYING FOR


DATE AVAILABLE

_____________________________

________________________

ARE YOU 21 YEARS OF AGE OR OLDER? YES

FULL TIME

State

_______________________________
_______________________________

SALARY/HOURLY RATE DESIRED

_____

Zip

PART TIME

_____

HOURS

_______________
______________

NO

ARE THERE ANY HOURS OR DAYS WHICH YOU CANNOT WORK? YES
NO
IF YES, WHAT ARE DAYS AND TIMES YOU CANNOT WORK: _____________________________________________________________
ANY RELATIVES WHO ARE DIRECTORS OR EMPLOYEES EMPLOYED BY US?
HAVE YOU PREVIOUSLY APPLIED OR BEEN EMPLOYED WITH US?

__________________________________

________________________________________

________________________________________________
___________________________________________________________________________________
WHY ARE YOU SEEKING A CHANGE IN EMPLOYMENT?

HAVE YOU EVER BEEN TERMINATED FROM EMPLOYMENT REGARDING A THEFT? YES
IF YES, PLEASE EXPLAIN:

NO

___________________________________________________________________________________
___________________________________________________________________________________
HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN A MISDEMEANOR? YES
IF YES, PLEASE EXPLAIN:

NO

___________________________________________________________________________________
___________________________________________________________________________________
PLEASE PROVIDE ANY ADDITIONAL INFORMATION SUCH AS SPECIAL SKILLS, TRAINING, MANAGEMENT EXPERIENCE, EQUIPMENT
OPERATION, OR OTHER QUALIFICATIONS YOU FEEL WOULD BE HELPFUL TO US IN CONSIDERING YOUR APPLICATION.

___________________________________________________________________________________
___________________________________________________________________________________

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EMPLOYMENT RECORD

BEGIN WITH YOUR MOST RECENT EMPLOYMENT (INCLUDING MILITARY).

DATES

NAME & ADDRESS

SALARY

JOB TITLE/ DUTIES

SUPERVISOR

REASON
FOR
LEAVING

OF EMPLOYER

REFERENCES
LIST FOUR BUSINESS REFERENCES WHO HAVE KNOWLEDGE OF YOUR ABILITY.
NAME

ADDRESS & TELEPHONE NO.

MAY WE CONTACT THE EMPLOYERS LISTED ABOVE? YES


IF NOT, WHICH ONE(S) AND WHY NOT:

JOB TITLE &


COMPANY

YEARS
KNOWN

NO

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

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EDUCATION

NAME & ADDRESS OF SCHOOL

MAJOR OR
COURSES

DEGREE

HIGH
SCHOOL

COLLEGE
OR
UNIVERSITY

OTHER
SCHOOLS

CAREER OBJECTIVES

PLEASE DESCRIBE YOUR CAREER OBJECTIVES:

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

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AGREEMENT

We are an equal opportunity employer and do not discriminate in recruiting, hiring, training,
promoting or other employment practices, on the basis of race, color, religion, sex, sexual orientation,
marital status, age, national origin, or veteran or handicap status, or any other legally protected
status. No question in this application is intended to obtain information to be used for such
discrimination.

I understand that I must be a U.S. Citizen or a properly authorized alien to qualify for
employment.

I understand that employment is for no definite period of time and it may be terminated at any
time by either the Company or me.

I agree to abide by all policies and rules and that all Company information is strictly confidential.

I understand that, prior to being offered employment, I may be requested to take an employment
examination.

I hereby authorize The Barleycorn to investigate all information in this application and to secure
additional information in the course of that investigation. I authorize all reference, and any other
persons contacted, to answer all questions asked related to my ability, reputation, character, and
previous employment record.

I certify that all statements by me on this application are true and complete and, if not, are causes
for disqualification or termination. This application is active for 60 days unless renewed by
applicant.

________________________________
Applicant Signature

_____________________________
Date

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