General Information

Position(s) applied for:
Referral Source:	Ad Employee Relative Walk-In Employment Agency Gov. Employment Agency Other --
Name of source (if applicable):
Full Name:
E-mail Address:
Social Security:	- -
Street Address:
City / State / Zip:	-- Select State / Province-- N/A --AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNorthwest TerritoriesNova ScotiaOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon
Primary Phone #:	() - 2nd Phone #: () -
Date available:	010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011
Desired Salary Range:
Type of employment:	Full-Time Part-Time Temporary Seasonal Educational Co-Op
Best time to call you at home is...
May we contact you at work?	Yes No If yes, work phone: () - Best time to call:

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If you are under 18 and it is required, can you furnish a work permit?	Yes No
If no, please explain:
Have you ever submitted an application to Western Rim?	Yes No
If yes, give date(s) and position applied for: Date: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 Position:
Have you ever been employed by Western Rim?	Yes No
If yes, give date(s) employed -- From: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 To: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011
Are you legally eligable for employment in this country?	Yes No
Will you relocate if job requires it?	Yes No
Will you travel if job requires it?	Yes No
Are you able to meet the attendance requirements of the position?	Yes No
Will you work overtime if required?	Yes No
If no, please explain:
Have you ever been bonded?	Yes No
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?	Yes No
If yes, please provide dates and details: Answering "Yes" to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

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Employment History

Previous Employer #1

Employer	Telephone # () -	Dates Employed From: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 To: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 Hourly Rate / Salary Starting: Final: May we contact for reference? Yes No Later
Address
Starting Job Title	Final Job Title
Immediate Supervisor / Title
Reason for Leaving Summarize the type of work performed and job responsibilities:

Previous Employer #2

Employer	Telephone # () -	Dates Employed From: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 To: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 Hourly Rate / Salary Starting: Final: May we contact for reference? Yes No Later
Address
Starting Job Title	Final Job Title
Immediate Supervisor / Title
Reason for Leaving Summarize the type of work performed and job responsibilities:

Previous Employer #3

Employer	Telephone # () -	Dates Employed From: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 To: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 Hourly Rate / Salary Starting: Final: May we contact for reference? Yes No Later
Address
Starting Job Title	Final Job Title
Immediate Supervisor / Title
Reason for Leaving Summarize the type of work performed and job responsibilities:

Previous Employer #4

Employer	Telephone # () -	Dates Employed From: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 To: 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 Hourly Rate / Salary Starting: Final: May we contact for reference? Yes No Later
Address
Starting Job Title	Final Job Title
Immediate Supervisor / Title
Reason for Leaving Summarize the type of work performed and job responsibilities:

Comments

Include explanation of any gaps in employment:

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related funtions in the position for which you are applying.

Educational Background

Last 3 schools attended:

School	Years Completed 12345678	Degree / Diploma
GPA or Class Rank	Major	Minor
School	Years Completed 12345678	Degree / Diploma
GPA or Class Rank	Major	Minor
School	Years Completed 12345678	Degree / Diploma
GPA or Class Rank	Major	Minor

References

List name and telephone number of three business / work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Name	Telephone	Years Known
		12345678
		12345678
		12345678

Additional Information

List professional, trade, business, or civic associations and any offices held.
Please exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran / reserve national guard or any other similary protected status.

Organization	Offices Held

List special accomplishments, publications, awards, etc.

Please exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran / reserve national guard or any other similary protected status.

List any additional information you would like us to consider:

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without proper notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be requird by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.