Employment Application

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Company: Ackerson Door Sales

Address: 2255 Illinois 173

City, State & Zip: Caledonia, IL 61011

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or the presence of a non-job related medical condition or handicap.

ANSWER ALL QUESTIONS

 

Name
Address
Who referred you?
Date of Application
Position(s) applied for
Rate of pay expected
SSN
Are you a US Citizen?
Date of Birth required for truck drivers
Can you provide proof of age?

PREVIOUS ADDRESSES

 

Address for the past three years
How long did you live at this address?
Address for the past three years (cont)
How long did you live at this address?

EMERGENCY CONTACT

 

Emergency Contact Name
Have you worked for this company before?

EMPLOYERS FOR THE LAST THREE YEARS

 

LAST employer name
Address
Position held
Salary
From
To
Reason for leaving
SECOND last employer name
Address
Position held
Salary
From
To
Reason for leaving
THIRD last employer name
Address
Position held
Salary
From
To
Reason for leaving

PHYSICAL HISTORY

 

Are you physically capable of doing heavy manual work?
Ever injured on the job?
How much time lost in last 3 years due to illness?
Are you willing to take a Physical Examination?

MILITARY SERVICES

 

Have you served in the U.S. Armed Forces?
From
To
Rank at discharge
Date at discharge

EDUCATION

 

Highest grade completed
High School
College

EXPERIENCE & QUALIFICATIONS - DRIVER

 

State
License Number
Type
Expiration Date
State
License Number
Type
Expiration Date
State
License Number
Type
Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Has any license, permit or privilege been suspended or revoked?
Date / From
Date / To
Date / From
Date / To
States operated in last 5 years
Any safe driving awards
Injuries
Fatalities
Next previous accident / Date
Injuries
Fatalities
Next previous accident / Date
Injuries
Fatalities