Application for Employment
Personal Information
Name (Last name first)
 Social Security Number
Present Address
 Permanent Address
Are you 18 years old or older?
             		Phone Number
Desired Employment
Position Desired
 Date you can start
 Salary Desired
Are you presently employed?
             		If so, may we contact your employer?
            
Have you applied here before?
             		If so, please state when and where
Have you worked here before?
             		If so, please state when and where
What were your reasons for leaving?
What was your supervisors name?

Who referred you to Valley Offset?
      
        

Education

Grammar school

School Name

# years attended

Did you graduate?
   

Location
 Subjects Studied

High school

School Name

# years attended

Did you graduate?
   

Location
 Subjects Studied

College

School Name

# years attended

Did you graduate?
   

Location
 Subjects Studied

Trade, business or correspondence school

School Name

# years attended

Did you graduate?
   

Location
 Subjects Studied

General

Subjects of Special Study or Research Work
Special Training
Special Skills
Former Employers
List the last three employers, starting with the most recent one first.
Name of present or last employer
Address
 City
 State
 Zipcode
Start Date
 Leave Date
 Job Title
Weekly starting salary
 		 Weekly final salary
 May we contact your supervisor?
   
Supervisor name
 Title
 Phone
Description of work
 Reason for leaving
Name of previous employer
Address
 City
 State
 Zipcode
Start Date
 Leave Date
 Job Title
Weekly starting salary
 		 Weekly final salary
 May we contact your supervisor?
   
Supervisor name
 Title
 Phone
Description of work
 Reason for leaving
Name of previous employer
Address
 City
 State
 Zipcode
Start Date
 Leave Date
 Job Title
Weekly starting salary
 		 Weekly final salary
 May we contact your supervisor?
   
Supervisor name
 Title
 Phone
Description of work
 Reason for leaving
Other Information

References
Give the names of three persons you are not related to, whom you have known at least one year.

Name Address Business Years
Acquainted

Service Record

Branch of service

Discharge date

Discharge rank

Criminal Record

Have you been convicted of a felony within the last 5 years?   

If yes, explain (will not necessarily exclude you from consideration)

AUTHORIZATION
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you and and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for and damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

I also understand and agree that my information is not being transmitted securely and I release the company from all liability for and damage that may result from utilization of such information.."