Apply

Position applied for
Date of application
MM slash DD slash YYYY
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Telephone
Cell
Email
How did you hear about us?
If your are under 18, and it is required, can you furnish a work permit?
- Yes
- No
If no, please explain
Have you ever been employed here before?
- Yes
- No
If yes, give dates and supervisors
Are you legally eligible for employment in this country?
- Yes
- No
Date available for work
MM slash DD slash YYYY
What is your desired salary range?
Type of employment desired
- Full-Time
- Part-Time
- Temporary
- Seasonal
Driver's license number

If driving may be required in position for which you are applying
State
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?
- Yes
- No
Answering “yes” to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
If yes, please provide date(s) and details

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Employment History
Starting with your most recent employer, provide the following information.
Employer
Phone
Date employed from
MM slash DD slash YYYY
Date employed to
MM slash DD slash YYYY
Address
Street Address City State
Starting Wage
Ending Wage
Starting job title
Ending job title
Immediate supervisor and title
May we contact for reference?
- yes
- no
- later
Why did you leave?
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What were the things you liked least about the position?
Employer 2
Employer
Telephone
Date employed from
MM slash DD slash YYYY
Date employed to
MM slash DD slash YYYY
Address
Street Address City State
Starting Wage
Ending Wage
Starting job title
Ending job title
Immediate supervisor title
May we contact for reference?
- yes
- no
- later
Why did you leave?
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What were the things you like least about the position?
Employer 3
Employer
Telephone
Date employed from
MM slash DD slash YYYY
Date employed to
MM slash DD slash YYYY
Starting Wage
Final Wage
Starting job title
Final job title
May we contact for reference?
- yes
- no
- later
Why did you leave?
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What were the things you liked least about the position?

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Skills and Qualifications
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:
Special training, skills, licenses and/or certificates
Computer Skills
- Word Processing
- Spreadsheet
- Presentation
- E-Mail
- Internet
Check where appropriate. Include software title and years of experience below
Computer Skills
Software Years

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Educational Background
Starting with your most recent school attended, provide the following information
Education
School Name City State Completed GPA/Class Rank Major Minor

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References
List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
References
Name Title Relationship Telephone Years Known

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Application Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I herby waive any and all right and claims that I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does no unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any application from consideration for employment on any basis prohibited by applicable local, state or federal law. I understand that this application remains current for 90 days. At the conclusion of that time, if I h ave not heard from the employer and still wish to be considered for employment, If I am hired, I understand that I am free to resign at any time, with our without cause and with our without prior notice, and the employer reserved the same right to terminate my employment at any time, with our without cause and with our without prior notice except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreement contrary to the foregoing express language are valid unless they are valid unless they are in writing and singed by the employer’s president. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States of American and that federal immigration laws require me to complete an I-9 Form in the regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (I) eliminate me from further consideration for employment, or (2) may result in my immediate discharge from the employer’s service, whenever it is discovered.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT
Signature of Applicant
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Date
MM slash DD slash YYYY

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Release Information
I hereby give my permission to release information concerning myself to Midstates Builders, Inc. and release the reference giver from all liability associated with this information.
Date
MM slash DD slash YYYY
Signature

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Employment History

Employer 2

Employer 3

Skills and Qualifications

Educational Background

References

Application Statement

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

List of Experience

Release Information

Links

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Software	Years

School Name	City State	Completed	GPA/Class Rank	Major Minor

Name	Title	Relationship	Telephone	Years Known