McCurry Inc. Application for Employment

Application for Employment
Name
Last First Middle
Email Address
Address
Street City State Zip

Phone Number

Social Security No

Date of Birth

Are you 18 years or older?	Yes No
Are you a US citizen?	Yes No
If not a US citizen, do you have the legal right to remain permanently in the United Sates?	Yes No

Have you been previously employed here?	Yes No
If yes, date(s): Supervisor Name(s):
Have you filed an application before?	Yes No
*If YES, date(s):*
List any friends or relatives working here:
What method of transportation will you use to come to work?

Employment Desired
Position Applying for:
Type of work sought:	Full Time Part Time Other
If part-time, please specify hours and days desired:
Do you have any special training, skills, qualifications or other experiences relating to the position(s) being applied for:
Yes No	If yes, explain:
Do you have any physical/medical or mental impairment/disability which would interfere with your ability to do the job for which you have applied?
Yes No	If yes, explain:
Salary desired	Date available to start work

Employment Experience (list current/most recent job first)

Employer	Dates		Work performed
	From	To

Address	Hourly rate/Salary		Job title
	Starting	Final

Supervisor		Reason for Leaving

Employer	Dates		Work performed
	From	To

Address	Hourly rate/Salary		Job title
	Starting	Final

Supervisor		Reason for Leaving

Employer	Dates		Work performed
	From	To

Address	Hourly rate/Salary		Job title
	Starting	Final

Supervisor		Reason for Leaving

Employer	Dates		Work performed
	From	To

Address	Hourly rate/Salary		Job title
	Starting	Final

Supervisor		Reason for Leaving

Employer	Dates		Work performed
	From	To

Address	Hourly rate/Salary		Job title
	Starting	Final

Supervisor		Reason for Leaving

References
	Name	Address	Phone number	Years Acquainted
1
2
3

Military Service Record
Any experience in the Armed Forces of the United States or in a State National Guard?	Yes No

If Yes, what branch? Rank at discharge Date of discharge:
Are you in the reserves?	Yes No	*If YES, date obligation ends:*
Special/Technical training:

Additional Information
Have you ever been convicted of a crime?	Yes No
If so, where, when and nature of offense:
Do you have a valid driver's license? Yes No License # State

List professional, trade, business or civic activities and offices held excluding groups the name or character which indicate race, color, religion, sex, national origin, handicap, marital or veterans status:

State additional information that you feel may be helpful in considering your application

Name, address, of the person to be notified in the event of accident or emergency:

Education
	Name / Location	Years completed	Diploma Degree	Courses of Study
Elementary			Yes No

High Schools			Yes No

Colleges			Yes No

Graduate			Yes No

Training/Vocational			Yes No

Any other educational training: