Date

Name First, Last

Phone Number

Address

City

State

Zip

How long at this Address?

eMail Address

Drivers License Number

Social Security Number

Have you ever been encarcerated?

Do you have a valid drivers license?

Do you have reliable transportation?

Can you lift a 20lb box?

Can you stand for extended periods (hours) of time?

Can you work Mondy thru Saturday?

I have experience in these areas:

Shipping

Hand Tools

Technology

Printers

MS Office

Quickbooks

Customer Service

Retail

Database or HTML

Automotive

I have had an accident within the last 3 years

I had a moving violation in the last 4 years

I have had more than 1 moving violation in the last 4 years

I have a CDL

I can drive a vehicle with a manual shift

I have received a DUI

I hold other government issued licenses

I can use a GPS

I am very good with maps

When is the best time to schedule a telephone interview?

Are you seeking Full or Part Time Employment?

How Many Hours Can You Work?

What is your highest level of education

Most Recent Date of Education

Diploma/Degree?

Last/Current Employer

Start/End Dates

City

Pay Rate $

Reason for leaving

Employer

Start/End Dates

City

Pay Rate $

Reason for leaving

Employer

Start/End Dates

City

Pay Rate $

Reason for leaving

Comments you would like to make about your work history

I attest that all information here is correct: Initials