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Personal Information

*Name

Address

City

State

Zip

Home Phone

Business Phone

*Email Address

May we respond to you via email? YesNo

Job Requirements

Position(s) Desired

Please mark all that apply
Full-timePart-timeTemporary or Contract

*Date Available

Annual Salary Expected
$

Education

High School Name & Location

Dates Attended

Graduated? YesNo

Major Subject

GPA

College

Dates Attended

Graduated? YesNo

Major Subject

GPA

Graduate or Business School

Dates Attended

Graduated? YesNo

Major Subject

GPA

Other

Dates Attended

Graduated? YesNo

Major Subject

GPA

List academic achievements, professional awards, and professional organizations in which you are a member

Military History

Branch & Service

Date Sworn In

Discharge Date

Rank at Time of Discharge

Special Training or Skills Acquired During Service

General Information

*Referred by
SelfKeller Schroeder EmployeeNewspaper AdInternet SiteEmployment AgencyOther

Specify Employment Agency or Other

*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? YesNo

*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? YesNo

*Are you a United States citizen? YesNo

If no, what visa classification do you hold?

*Have you ever been convicted of a crime, excluding misdemeanors and summary offenses? YesNo

If yes, explain

*Have you ever applied here before? YesNo

If yes, when?

*Have you ever worked here before? YesNo

If yes, when?

*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? YesNo

Employment History

Employment history for the past 10 years. List present or most recent position first.

Most Recent

From (mm/yy)     To (mm/yy)

Job Title

Name of Company

Address, City, State, Zip Code (actual work location)

Supervisor's Name and Title

Can Keller Schroeder contact? YesNo

Starting Compensation | Base: $     Bonus: $

Ending Compensation | Base: $     Bonus: $

Reason for Seeking Change

Description of Duties

Previous 1

From (mm/yy)     To (mm/yy)

Job Title

Name of Company

Address, City, State, Zip Code (actual work location)

Supervisor's Name and Title

Can Keller Schroeder contact? YesNo

Starting Compensation | Base: $     Bonus: $

Ending Compensation | Base: $     Bonus: $

Reason for Seeking Change

Description of Duties

Previous 2

From (mm/yy)     To (mm/yy)

Job Title

Name of Company

Address, City, State, Zip Code (actual work location)

Supervisor's Name and Title

Can Keller Schroeder contact? YesNo

Starting Compensation | Base: $     Bonus: $

Ending Compensation | Base: $     Bonus: $

Reason for Seeking Change

Description of Duties

Previous 3

From (mm/yy)     To (mm/yy)

Job Title

Name of Company

Address, City, State, Zip Code (actual work location)

Supervisor's Name and Title

Can Keller Schroeder contact? YesNo

Starting Compensation | Base: $     Bonus: $

Ending Compensation | Base: $     Bonus: $

Reason for Seeking Change

Description of Duties

Previous 4

From (mm/yy)     To (mm/yy)

Job Title

Name of Company

Address, City, State, Zip Code (actual work location)

Supervisor's Name and Title

Can Keller Schroeder contact? YesNo

Starting Compensation | Base: $     Bonus: $

Ending Compensation | Base: $     Bonus: $

Reason for Seeking Change

Description of Duties

Previous 5

From (mm/yy)     To (mm/yy)

Job Title

Name of Company

Address, City, State, Zip Code (actual work location)

Supervisor's Name and Title

Can Keller Schroeder contact? YesNo

Starting Compensation | Base: $     Bonus: $

Ending Compensation | Base: $     Bonus: $

Reason for Seeking Change

Description of Duties

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.

Reference 1 | *Keller Schroeder can contact this reference? YesNo

*Name

Job Title

Company Name & Address

Phone Number

SupervisorColleagueOther

Reference 2 | *Keller Schroeder can contact this reference? YesNo

*Name

Job Title

Company Name & Address

Phone Number

SupervisorColleagueOther

Reference 3 | *Keller Schroeder can contact this reference? YesNo

*Name

Job Title

Company Name & Address

Phone Number

SupervisorColleagueOther

Attachments

Applicant's Certification

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.