Triple "S" Building Center

PERSONAL

Email Address:

Last Name:

First Name:

Middle Name:

Home Phone:

Position Desired:

Pay Expected:

Are you legally eligible for employment in the US?

Have you been convicted of a felony within the last 7 years?

Conviction will not necessarily disqualify an applicant from employment

If yes, please explain

EDUCATION

Name & Address of School:

Years Completed:

Elementary

High School

College

Other(Specify)

If you completed college, what degree did you receive?

Other special training or skills (languages, machine operation, etc.)

Membership in Professional or Civic Organizations
(Exclude those which may disclose your race, color, religion or national origin)

EMPLOYMENT 1

Company Name:

Address:

Name of Supervisor:

Telephone:

Time Employed:

Start Date (month and year):

End Date (month and year):

Weekly Pay:

Start:

Last:

Reason for Leaving

State Job Title and Describe Your Work

EMPLOYMENT 2

Company Name:

Address:

Name of Supervisor:

Telephone:

Time Employed:

Start Date (month and year):

End Date (month and year):

Weekly Pay:

Start:

Last:

Reason for Leaving

State Job Title and Describe Your Work

EMPLOYMENT 3

Company Name:

Address:

Name of Supervisor:

Telephone:

Time Employed:

Start Date (month and year):

End Date (month and year):

Weekly Pay:

Start:

Last:

Reason for Leaving

State Job Title and Describe Your Work

EMPLOYMENT 4

Company Name:

Address:

Name of Supervisor:

Telephone:

Time Employed:

Start Date (month and year):

End Date (month and year):

Weekly Pay:

Start:

Last:

Reason for Leaving

State Job Title and Describe Your Work

MILITARY

Did you service in the U.S. Armed Forces?

If yes, in what Branch?

Describe any training relevant to the position for which you are applying.

REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR
	Name:	Address:	Phone:	Years Acquainted
1
2
3

EMERGENCY CONTACT
Name:
Address:
Phone:

ADDITIONAL INFO
State any additional information you feel may be helpful to us in considering your application.

SUBMIT APPLICATION

By submitting this form you certify that the answers given above are true and complete to the best of your knowledge.

You authorize investigation of all statements contained in this application. You understand that misrepresentation or omission of facts called for is cause for dismissal. Further, you understand and agree that your employment is for no definite period and may, regardless of the date of payment of my wages or salary, be terminated at any time without any previous notice.

PERSONAL

EDUCATION

EMPLOYMENT 1

EMPLOYMENT 2

EMPLOYMENT 3

EMPLOYMENT 4

MILITARY

REFERENCES:

EMERGENCY CONTACT

ADDITIONAL INFO

SUBMIT APPLICATION