PERSONAL INFORMATION:

Name (Last, First, Middle):

Date:

Present Address (Street, City, State, Zip):

Permanent Address (Street, City, State, Zip):

Phone Number:

State Name and Relationship of any Relatives
in our Employ:

Referred By:

EMPLOYMENT DESIRED:

Position:

Date You can Start:

Salary Desired:

Are You Employed Now?

May We Contact Your Employer?

Have You Ever Applied To This Company Before?

When?

Where?

EDUCATION:

School

Name and Location

Graduated

Major Subjects

GPA

Grammar
School

Yes

No

High
School

College/
University

Other
(Specify)

OTHER INFORMATION:

Subjects of Special Study or Research Work:

Special Training:

Activities: (Civic, Athletic, ETC.)

Exclude organizations, the name or character of which indicates race, creed sex, marital status, age, color, or national origin of its members.

FORMER EMPLOYERS:

List the last four employers, starting with present or most recent.

Date
Month and Year

Name and Address of Employer

Salary

Position

Reason For Leaving

From:

To:

$
Per:

From:

To:

$
Per:

From:

To:

$
Per:

From:

To:

$
Per:
REFERENCES:

Give the names of three persons not related to you, whom you have known at least one year.

Name

Address

Business

Years
Acquainted

....Have you ever been convicted of violating any law (omit minor traffic violations)? If yes, list conviction(s), date(s), and place(s).

Conviction is not an automatic rejection. Specifics will be reviewed under KRS335B.020