Phone (801) 475-6785
  Fax (801) 475-6786                                        Employment Application
Applicant Information	
Last Name		First		M.I.	Date		
Street Address		Apartment/Unit #		
City		State		ZIP		
Phone		E-mail Address		
Date Available		Social Security No.		Desired Salary		
Position Applied for		
Are you authorized to work in the U.S.?	YES  	NO  	 			
Have you ever worked for this company?	YES  	NO  	If so, when?		
Have you ever been convicted of a felony?	YES  	NO  	If yes, describe		
	
Education	
High School		Address		
From		To		Did you graduate?	YES  	NO  	Degree		
College		Address		
From		To		Did you graduate?	YES  	NO  	Degree		
Certifications				
OSHA 10 Hr Safety Certification?	YES     NO  

References	
Please list three professional references.	
Full Name		Relationship		
Company		Phone	(           )	
Address		
Full Name		Relationship		
Company		Phone	(           )	
Address		
Full Name		Relationship		
Company		Phone	(           )	
Address		

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 a 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 a reference?	YES  	NO  		
Company		Phone	(         )	
Address		Supervisor		
Job Title		Starting Salary	$	Ending Salary	$	
Responsibilities		
May we contact your previous supervisor for a reference?	YES  	NO  		
bACKGROUND CHECK	
Are you willing to submit to a criminal background check? 	YES  	NO  			
	
Military Service	
Branch		From		To		
Rank at Discharge		Type of Discharge		
If other than honorable, explain		
	
Disclaimer and Signature	
I certify that my answers are true and complete to the best of my knowledge. 
If this application leads to employment, I understand that false or misleading information in my application or interview 
may result in my release.	
Signature		Date