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APPLICANT INFORMATION
   Last Name 
First                Date 
   Street Address 
Apt./Unit # 
   City  
State                ZIP 
   Phone  
Email 
   Date Available 
SSN  (Social Security Number)
Position desired 
   Have you ever worked for this company? 
YES NO
If so, when? 
   Have you ever been convicted of a felony? 
YES NO
If yes, explain 
 
JOB RELATED SKILLS
     Do you have a valid Driver's License? 
YES NO
DL#  
  Type   State 
     Have you had your Driver's License suspended or revoked in the last three years?
   YES NO
     If yes, please give details
     Do you have adequate transportation to get to work on time each day? 
   YES NO
     
     List any skills that would be of value to this job or company
     
     List any certifications or licenses that may be job related
 
PREVIOUS EMPLOYMENT
     Company    Phone
     Address    Supervisor
     Job Title   Starting Salary   Ending Salary
     Responsibilities
     From  To   Reason for Leaving
     May we contact your previous supervisor for reference?
   YES NO
     Company    Phone
     Address    Supervisor
     Job Title   Starting Salary   Ending Salary
     Responsibilities
     From  To   Reason for Leaving
     May we contact your previous supervisor for reference?
   YES NO
     IN CASE OF EMERGENCY Name Relationship Phone
 
ARE YOU ABLE TO DO THE FOLLOWING (Answer Yes or No)
Physical Demand Total per Day Able to Perform
     Standing 1-10+ Hours per Day  YES NO
     Walking 1-10+ Hours per Day  YES NO
     Bending/Stooping 1-10+ Hours per Day  YES NO
     Kneeling 1-10+ Hours per Day  YES NO
     Squatting 1-10+ Hours per Day  YES NO
     Twisting 1-10+ Hours per Day  YES NO
     Crawling 1-10+ Hours per Day  YES NO
     Reach Above Shoulders 1-10+ Hours per Day  YES NO
     Reach Waist-Shoulder 1-10+ Hours per Day  YES NO
     Reach Knee-Waist 1-10+ Hours per Day  YES NO
     Reach Floor-Knee 1-10+ Hours per Day  YES NO
     Lift/Carry 1-10#    YES NO
     Lift/Carry 11-20#    YES NO
     Lift/Carry 21-50#    YES NO
     Lift/Carry 51-100#    YES NO
     Lift/Carry 100+#    YES NO
     Climb Stairs    YES NO
     Climb Ladders/Scaffolding    YES NO
     Work @ Heights    YES NO
     Repetitive Movements    YES NO
         
How Would You Rate Your Good Fair Poor or No
     Vision (to ensure safety of others)
     Hearing (to ensure safety of others)
     Tolerance of Heat
     Tolerance of Cold
     Verbal Communicate in English
     Written Communicate in English
     Verbal Communicate in Spanish
     Written Communicate in Spanish
 
DISCLAIMER AND SIGNATURE
     Signature    Date