APPLICATION FOR EMPLOYMENT
09/05/2008
4920 Carriage Drive Evansville, Indiana 47715-2578
Phone (812) 474-6825 Fax (812) 474-6835
AN EQUAL OPPORTUNITY EMPLOYER
.
Items beginning with
*
are required.
PERSONAL INFORMATION
Name
*
First:
Middle:
*
Last:
Present Address:
City:
State:
Zip Code:
Home Telephone No.
Business Telephone No.
May we respond to you via e-mail?
Yes
No
If Yes, e-mail address:
JOB REQUIREMENTS
Position(s) Desired:
Date Available(mm/dd/yy):
Please mark all that apply.:
Full-time
Part-time
Temporary or Contract
Salary Expected: $
EDUCATION
School
Name and Location
Dates Attended
Academic Status
Major Subject
Grade Point Average
From
To
Mo
Yr
Mo
Yr
High School
Graduated?
Yes
No
College
Graduated?
Yes
No
Degree:
Graduate or
Business School
Graduated?
Yes
No
Degree:
Other
Graduated?
Yes
No
Degree:
List academic achievements, professional awards and professional organizations in which you are a member:
MILITARY HISTORY
Special Training or Skills Acquired During Service
Date Sworn In(mm/yy):
Branch & Service:
Date of Discharge(mm/yy):
Rank at time of Discharge:
GENERAL INFORMATION
*
Referred by :
Self
Keller Schroeder Employee
Newspaper Ad
Internet Site
Employment Agency
Other
Employment Agency-specify:
Other-specify:
*
Have you entered any agreement with any person or company which would prevent you from disclosing or would otherwise limit
your disclosure of business or technical information considered confidential by that person or company?
Yes
No
*
Have you entered any agreement with any person or company which would prohibit you from working for
Keller Schroeder such as a non-compete agreement?
Yes
No
*
Are you a United States citizen?
Yes
No
If no, what visa classification do you hold?
*
Have you ever been convicted of a crime, excluding misdemeanors and summary offenses?
Yes
No
If yes,
explain:
*
Have you ever applied here before?
Yes
No
If yes, when(mm/dd/yyyy):
*
Have you ever worked here before?
Yes
No
If yes, when(mm/dd/yyyy):
*
We have a tobacco free environment. If you are a tobacco user, do you understand that you cannot use tobacco in the Company
work environment?
Yes
No
EMPLOYMENT HISTORY
Employment History for the past 10 years. List present or most recent position first.
From (mm/yy):
To (mm/yy):
Job Title:
Name of Company:
Address, City, State, Zip Code (list actual work location):
Supervisor's Name and Title:
Can Keller Schroeder contact?
Yes
No
Supervisor's Phone Number:
Starting Compensation:
Base:
Bonus:
Ending Compensation:
*
Base:
Bonus:
Reason for Seeking Change:
Description of Duties:
Click here to add another Employment History.
PROFESSIONAL REFERENCES
Please list three(3) references. If possible, include one or more individuals who have
directly supervised your work. Indicate any you do NOT want us to contact at this time.
*
Keller Schroeder can contact this reference?
Yes
No
*
Name:
*
Job Title:
*
Supervisor
Colleague
Other
*
Company Name & Address:
*
Phone #:
*
Keller Schroeder can contact this reference?
Yes
No
*
Name:
*
Job Title:
*
Supervisor
Colleague
Other
*
Company Name & Address:
*
Phone #:
*
Keller Schroeder can contact this reference?
Yes
No
*
Name:
*
Job Title:
*
Supervisor
Colleague
Other
*
Company Name & Address:
*
Phone #:
ATTACHMENTS
Please attach resume, additional employment history or references, etc.
APPLICANT'S CERTIFICATION
By placing a check mark in the boxes below, you are agreeing to the following statements.
Yes
Age:
I certify that I am at least 18 years of age.
Yes
Truthfulness of Information Furnished:
I certify that the information which I have furnished on this application is true and complete, and I understand that any misrepresentation may result in my not being employed or dismissal if employed.
Yes
I understand that as a condition of employment with Keller Schroeder, a drug screen and background check is required. By marking the box to the left I give my consent, and I understand I will not be considered for employment without successful completion of a drug screen and background check.