(PLEASE PRINT)
Date of Application: _ _/_ _/_ _
Position(s) Applied For: ____________________________________________
Referral Source:

• Advertisement
  
• Employment Agency
  
• Friend
  
• Relative
  
• Walk-In
  
• Other: ______________________________________
  
  

Name: __________________________ __________________________ _________________
Last First Middle In.

Address: ___________ ______________________ ______________ ____ ____________
Number Street City State Zip Code

Telephone: ( _ _ _ ) _ _ _ - _ _ _ _ Social Security Number: _ _ _ - _ _ - _ _ _ _
If employed and you are under 18, can you furnish a work permit? _____Yes _____No
Have you filed an application here before? _____Yes _____No If yes, give date: _ _/_ _/_ _
Have you ever been employed here before? _____Yes _____No If yes, give date: _ _/_ _/_ _
Are you employed now? _____Yes _____No
May we contact your employer? _____Yes _____No
Are you prevented from lawfully becoming employed in this country
because of Visa or Immigration Status? _____Yes _____No
(Proof of citizenship or immigration status will be required upon employment)
On what date would you be available for work? _ _/_ _/_ _
Are you available to work _____Full Time _____Part-time _____Shift Work _____Temporary
Are you on a layoff and subject to recall? _____Yes _____No
Can you travel if a job requires it? _____Yes _____No
Have you been convicted of a felony wihtin the last 7 years? _____Yes _____No
If yes, please explain_______________________________________________________
_______________________________________________________________________

EMPLOYMENT EXPERIENCE or REFERENCES

Employer/Reference	Company Phone Number
Address
Employer's Job Title/Relationship to Reference
Name of Supervisor	Supervisor's/Reference's email address
Reason for Leaving
Employer/Reference	Company Phone Number
Address
Employer's Job Title/Relationship to Reference	Supervisor's/Reference's email address
Name of Supervisor
Reason for Leaving

(Above, list all jobs in order starting with your present or last job, OR indicate two references. Include military service assignmnet and volunteer activities. You may exlude organization names which indicate race, color, religion, gender, national origin, handicap, or other protected status.)

SPECIFIC SKILLS AND QUALIFICATIONS
Summarize special skills and qualifications acquired from previous employment or other experience that you have gained which will add to your success in this job. _____________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Are you physically and mentally able to perform the essential duties of the job for which you are applying, either with or without accomodation? _____Yes _____No

If workplace accomodation is required, please describe: __________________________________
______________________________________________________________________________
______________________________________________________________________________

EDUCATION

	Elementary	High
School Name
Years Completed	4 5 6 7 8	9 10 11 12
Did You Graduate?	___Yes ___No	___Yes ___No
Grade Point Average
Courses of Study: List the general courses you've taken and completed.
Describe any Specialized Training, Apprenticeship, Skills and/or Extra-Curricular Activities
Honors Received: State any additional information you feel may be helpful to us in considering your application.

AVAILABILITY (HOURS)

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
From
To

Total hours available to work each week: ____________

How far do you live from Bluestreak Employment Services? _______________

Do you have transportation to work? _____Yes _____No

READ BEFORE SIGNING

1. I certify that the information contained in this application is correct to the best of my knowledge and understand that any omission or erroneous information is grounds for dismissal in accordance with the Bluestreak Employment Services policy.

2. I authorize the references listed above to give you any and all information concerning my previous employment and pertinent information they may have.

3. I acknowledge that Bluestreak Employment Services reserves the right to amend or modify the policies in its Handbook at any time, without giving prior notice.

4. I understand that as a part of the procedure for my employment application, an investigative consumer report may be made concerning my character, general reputation, personal characteristics and mode of living. Upon written request, additional disclosure concerning the complete nature and scope of the investigation will provided. If I am denied a job based either wholly or in part because of information contained in an investigative consumer report, I will be provided the name and address of the reporting agency that supplies the information.


SIGNATURE:__________________________ DATE:_ _/ _ _/ _ _

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