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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:
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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Balfurd 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