Employer: Address/City: Name of Supervisor: Employed from: (mo/yr) to: (mo/yr) Type of Work Performed: Present or Last Salary: Reason for Leaving: Employer: Address/City: Name of Supervisor: Employed from: (mo/yr) to: (mo/yr) Type of Work Performed: Present or Last Salary: Reason for Leaving: Employer: Address/City: Name of Supervisor: Employed from: (mo/yr) to: (mo/yr) Type of Work Performed: Present or Last Salary: Reason for Leaving: EDUCATION Schools (name & location) Years Completed Major Course Diploma or Degree If you served in the U.S. Armed Forces, briefly describe skills acquired: PERSONAL INFORMATION Are you legally authorized to work in the U.S.? Yes No (Note: you will be required to furnish documents to verify your eligibility for employment in accordance with the Immigration reform and Control Act and your employment is contingent upon furnishing such documents.) Have you ever worked for another employer under a different name? Yes No If so, please list: Are you at least 18 years of age? Yes No Have you ever been convicted of a crime (felony)? Yes No (a conviction does not automatically bar you from employment) If yes, give details: If you are an experienced operator of any office machines or equipment, please list: If you are an experienced operator of any plant machines or equipment, please list: Do you have any other skill you wish to mention? Are you presently employed? Yes No If so, may we contact your employer? Yes No If hired, when would you be available to start? Salary requirements? REFERENCES Name: Occupation: Address: Phone: Name: Occupation: Address: Phone: I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind. I agree that the company shall not be held liable in any respect if my employment is terminated because of false statements, answers or omissions made by me in this application. I understand that any misleading or incorrect statements may render this application void, and if employed, may be cause for termination. I included as part of the regular pre-employment physical. I also authorize the companies, schools or persons named above to give any information requested regarding my employment, character and qualifications. I hereby release said companies, schools or persons from all liability for any damage for issuing this information. In consideration of my employment, I agree to conform to the rules and regulations of this organization. My employment and compensation can be terminated with or without cause, and with or without notice, at anytime, at the option of either my employer or myself. Lutheran Homes and Health Services, Inc. 244 North Macy Street Fond du Lac, WI 54935-3362 920-921-9520 Fax: 920-921-0819 info@fdllutheranhome.org
