Application Employment Form Page

Employment Application

Candidate's Name:

Email Address:

Date:

Address:

Telephone Number:

Are you 18 years of age or older?
YesNo

Are you either a U.S. citizen or an alien authorized to work in the U.S.?
YesNo

Have you ever worked or attended school under another name? If so, under what name?

Position Desired

Position:

Start Date Available:

Wage rate desired: ($)

Hidden
HourlyMonthlyAnnually

Do you prefer:
Full-timePart-time

If part-time, hours per week desired:

Hours you are available to work:

Days of week you are available to work:

Are you able to work:
WeekendsHolidaysNightsOvertime

Have you previously worked for Campello-Keith Oil?
YesNo

Dates of Employment with Camplello-Keith Oil:

From

to

Reason(s) for leaving:

Former supervisor(s) at this company:

How did you learn about this opening?:

Education

High School:	Graduated? YesNo	Course of study:
Technical School:	Graduated? YesNo	Course of study:
College/university:	Graduated? YesNo	Course of study:
Post-Graduate Education:	Graduated? YesNo	Course of study:
Other education, training, or special skills:

Skills for Office Position

Typing speed (WPM):

Are you experienced in using personal computers?
YesNo
PCMac

Are you able to use [name any software programs that are required for the position, e.g., Microsoft Word or Excel]. What other programs are you capable of using?

Work Experience

Please list all previous employment, beginning with the most recent. If you need more room, you may attach another sheet of paper.
Employer:	Address:
From to	Position Held:	Reason for Leaving:
Supervisor's Name, Title and Phone Number:		May we contact? YesNo
Description of Duties:
Starting Compensation:	Final Compensation:

Employer:	Address:
From to	Position Held:	Reason for Leaving:
Supervisor's Name, Title and Phone Number:		May we contact? YesNo
Description of Duties:
Starting Compensation:	Final Compensation:

References

Identify three persons who know your work, beginning with the most recent.

Name:

Phone Number:

Email:

Address:

Position or Title:

Years Known:

Name:

Phone Number:

Email:

Address:

Position or Title:

Years Known:

Name:

Phone Number:

Email:

Address:

Position or Title:

Years Known:

Authorization and Acknowledgements

I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for discharge.

I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.

Candidate's Signature:

Date:

Thank you for your interest in employment with Campello-Keith Oil.

We will keep your application on file and be in touch if an opportunity arises for the position you are interested in.

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