This document is an application for employment at Balfurd, an equal opportunity employer. It requests personal information such as name, address, phone number, and availability. It asks about the position applied for and willingness to relocate or travel. It inquires about past employment, including at Balfurd or its subsidiaries. It also asks about the applicant's ability to legally work in the US and any convictions. Further sections address job function abilities, education history, driving record if a vehicle is required, work history for the past 10 years, and military service. The applicant must sign and date to complete the application.

1. BALFURD APPLICATION FOR EMPLOYMENT
An Equal Opportunity Employer Today’s Date: ____________
PERSONAL INFORMATION Please Print or Type
Name (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 FUNCTIONS
Are 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 ____No
If you indicated you can perform all the functions with an accommodation, please explain how you would perform the tasks
and with what accommodations?
EDUCATION
School Level School Name & Address Number of years Did you graduate? Course of Study
attended
High School
Vo-Tech, Business
Or Trade School?
College
Graduate School?
PERSONAL DRIVING RECORD
This section is to be completed ONLY if the operation of a motor vehicle will be required in the course of the applicant’s
employment.
How long have you been a licensed driver? D.L.# Expiration Date Issuing State
List 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 ____No
Has 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 HISTORY
Please 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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