DATE: 10/26/05
NAME
Last Name:
First Name:
Middle:
PRESENT ADDRESS
Street:
City:
State:
Zip:
PERMANENT ADDRESS
Street:
City:
State:
Zip:
PHONE NUMBER


IN CASE OF EMERGENCY, please notify:
NAME
Last Name:
First Name:
Phone:
ADDRESS
Street:
City:
State:
Zip:

POSITION APPLIED FOR:
DATE YOU CAN START WORK:
SALARY DESIRED:
AVAILABILITY:
Weekdays
Weekends
Nights
Overtime
Other:
REFERRAL SOURCE(S):
Advertisement
Employee
Relative
School
Walk-In
Website
Government Employment Agency
Private Employment Agency
Other:


Are you 18 years of age or older?
If hired, can you provide the documents required to prove that you are authorized work in the United States?
Are you employed now?
If yes, give dates:
To:
May we contact you at work?
If yes, work number and best time to call:
Time:
If necessary, best time to call you at home:
Are you on layoff and subject to recall?
Have you ever applied to this company before?
If yes, give dates:
Have you ever been employed here before?
If yes, give dates:
From:
To:


SKILLS AND/OR ADDITIONAL COMMENTS: Describe any special training/skills (i.e. language, typing, machine operation) or any additional information that relates to your ability to perform the job for which you have applied (i.e. licenses, professional membership)


EDUCATION NAME & LOCATION
OF SCHOOL		 YEARS
ATTENDED		 DID YOU
GRADUATE?		 SUBJECTS
STUDIED
GRAMMAR
HIGH SCHOOL
COLLEGE
TECH TRAINING/OTHER


EMPLOYMENT HISTORY: List below last (3) employers, including military experience, starting with most recent.
FROM
 TO
 EMPLOYER
 TELEPHONE
JOB TITLE
 ADDRESS
IMMEDIATE SUPERVISOR
 SUMMARIZE NATURE OF WORK PERFORMED OR JOB RESPONSIBILITIES
SUPERVISOR'S TITLE
REASON FOR LEAVING
 HOURLY RATE/SALARY
START PER
FINISH PER

FROM
 TO
 EMPLOYER
 TELEPHONE
JOB TITLE
 ADDRESS
IMMEDIATE SUPERVISOR
 SUMMARIZE NATURE OF WORK PERFORMED OR JOB RESPONSIBILITIES
SUPERVISOR'S TITLE
REASON FOR LEAVING
 HOURLY RATE/SALARY
START PER
FINISH PER

FROM
 TO
 EMPLOYER
 TELEPHONE
JOB TITLE
 ADDRESS
IMMEDIATE SUPERVISOR
 SUMMARIZE NATURE OF WORK PERFORMED OR JOB RESPONSIBILITIES
SUPERVISOR'S TITLE
REASON FOR LEAVING
 HOURLY RATE/SALARY
START PER
FINISH PER


REFERENCES: List name and phone number of three (3) business/wrk references who are NOT previous supervisors. If not applicable , list (3) school or personal references (not related to you) whom you have known at least one (1) year.
YEARS KNOWN

NAME

NAME OF BUSINESS

CITY/STATE

TELEPHONE


MIDWEST INDUSTRIES, INC. is an Equal Opportunity Employer and does not discriminate in employment. No question on this application is sued for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law.

This application will be kept on file for a one (1) year period and will be reviewed upon job openings. All applications will be examined monthly and any "expired" forms will be removed and destroyed. At the conclusion of this time, if the applicant still wishes to be considered for employment, it will be necessary to fill out a new application. If an applicant updates his/her application, the one (1) year clock will be restarted.


BY SUBMITTING THIS APPLICATION I AGREE TO THE FOLLOWING:
  • I agree that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the Employer's service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

  • I give the Employer the right to investigate all references and to secure any additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.

  • I understand and agree that I shall be required to take a medical examination as a condition of employment. I understand a job offer is made contingent upon the results of a the job-specific medial examination. I agree to consent to take such tests, to include drug and/or alcohol screening, at such time as designated by the employer and to release the Employer, its directors, officers, agents, or employees from any claim arising in connection with the use of such test.



Hwy 59 & 175 ~ Ida Grove, Iowa 51445 ~ 800-859-3028 ~ E-mail