Job Application

PERSONAL INFORMATION

First, Middle, and Last Name*

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Mobile Phone

Home Phone

Are you eligible to work in the United States?*

Yes
No

Are you 18 years of age?*

Yes
No

Have you ever been terminated from employment or asked to resign by an employer?*

Yes
No

If yes, please provide details:

Preferred times available for work:

Can you work overtime &/or weekends?*

Yes
No

Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?*

Yes
No

EMPLOYMENT DESIRED

Date you can start:

Pay rate desired:

Position desired

Are you currently employed?*

Yes
No

If so may we inquire of your present employer?

Yes
No

REFERRAL SOURCE

How did you hear about us?

Walk In
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Referral
Other

Have you ever worked for this company before?*

Yes
No

If yes, provide approximate date(s):

Were you referred by a current employee?*

Yes
No

If yes, who?

EDUCATION

High School

Name and location of school, Number of years attended, Degree received, Subjects studied/Major

College or University

Name and location of school, Number of years attended, Degree received, Subjects studied/Major

Trade, Business or Correspondence School

Name and location of school, Number of years attended, Degree received, Subjects studied/Major

EMPLOYMENT HISTORY

Include your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration.

Company Name, Address, Phone, Dates of Employment, Position, Supervisor, Reason for Leaving

Do you have any special skills, experience, certifications and/or training that would enhance your ability to perform the position applied for? If yes, explain.

REFERENCES

Give the names of three professional references.

Name, Phone and/or Email, Company, Years Acquainted

Please read carefully before signing.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Midtex to hire me. If I am hired, I understand that either Midtex or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Midtex has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to Midtex true and complete information on this application. No requested information has been concealed. I authorize Midtex to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.

Date

Signature*

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Job Application

PERSONAL INFORMATION

EMPLOYMENT DESIRED

REFERRAL SOURCE

EDUCATION

EMPLOYMENT HISTORY

REFERENCES

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