Balfurd Application

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  • 1. BALFURD APPLICATION FOR EMPLOYMENTAn Equal Opportunity Employer Today’s Date: ____________PERSONAL INFORMATION Please Print or TypeName (Last) (First) (Full Middle) D.O.B. Social Security #Current Address City State Zip Code Phone Number: Cell Number:What position are you applying for? Date available for employment? Email Address:Are you willing to relocate? Are you willing to travel if required? Any restriction on hours, weekends, or____Yes ____No ____Yes ____No Overtime? If yes, explain.Have you ever been employed by this Company or any of its Indicate location and dates of employment:subsidiaries before?Can you submit verification of your legal right to work in the Have you ever been convicted of a felony?United States? (Convictions will not automatically disqualify job candidates. The seriousness of the crime and the date of conviction will be considered.)____Yes ____No ____Yes ____No (if yes explain)PERFORMANCE OF JOB FUNCTIONSAre you able to perform all the functions of the job for which you are applying, with our without accommodation? ____Yes, without accommodation ____Yes, with accommodation ____NoIf you indicated you can perform all the functions with an accommodation, please explain how you would perform the tasksand with what accommodations?EDUCATIONSchool Level School Name & Address Number of years Did you graduate? Course of Study attendedHigh SchoolVo-Tech, BusinessOr Trade School?CollegeGraduate School?PERSONAL DRIVING RECORDThis section is to be completed ONLY if the operation of a motor vehicle will be required in the course of the applicant’semployment.How long have you been a licensed driver? D.L.# Expiration Date Issuing StateList any other state(s) in which you have had a driver’s licenses(s) in the past:Within the last 5 years have you had any Been convicted of reckless or Been cited for moving violations?Vehicle accidents? Drunken driving? ____Yes ____No____Yes ____No ____Yes ____NoHas your driver’s license ever been revoked or suspended? ____Yes ____No Is your driver’s license restricted?If yes, explain: ____Yes ____No If yes, explain:
  • 2. WORK HISTORYPlease list your work experience for the past 10 years beginning with your most recent job held. If you were self-employed,please give the name of business. Name and Address of Employer Name of last Supervisor Employment Date & Salary Telephone Contact: Job title: Reason for Leaving: Job held, duties performed, skills used or learned, advancements/promotions: Name and Address of Employer Name of last Supervisor Employment Date & Salary Telephone Contact: Job title: Reason for Leaving: Job held, duties performed, skills used or learned, advancements/promotions: Name and Address of Employer Name of last Supervisor Employment Date & Salary Telephone Contact: Job title: Reason for Leaving: Job held, duties performed, skills used or learned, advancements/promotions: Name and Address of Employer Name of last Supervisor Employment Date & Salary Telephone Contact: Job title: Reason for Leaving: Job held, duties performed, skills used or learned, advancements/promotions:MILITARY Have you ever been in the Armed Forces? ____Yes ____No Are you now a Member of the National Guards? ____Yes ____No Specialty:*We are an Equal Opportunity Employer. We do not discriminate on the basis of race, religion, color,gender, age, national origin or disability.*_________________________________________ ____________________________________Signature Date
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