Print this page, fill in the information requested and fax it to. (570) 344-3598
PLEASE PRINT. APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS.
PLEASE COMPLETE PAGES 1-4.
DATE ________________________________
Name ______________________________________________________________________________________
Last First Middle Maiden
Present address ______________________________________________________________________________________
Number Street City State Zip
How long ____________________Social Security No. _______ – _____ – _________
Telephone ( ___________) If under 18, please list age _____________________
Position applied for (1) ________________________
and salary desired (2) ________________________(Be specific)
Days/hours available to work No Pref _______ Thur ________Mon __________ Fri __________Tue __________ Sat _________Wed _________ Sun ________
How many hours can you work weekly? _________________________
Can you work nights? _______________________
Employment desired__ FULL-TIME ONLY__ PART-TIME ONLY__ FULL- OR PART-TIME
When available for work?_______________________________________________
HAVE YOU EVER BEEN CONVICTED OF A CRIME?__ No__ Yes If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
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Page 2
PLEASE PRINT ALL INFORMATION REQUESTED.
DO YOU HAVE A DRIVER’S LICENSE?__ Yes __ No
What is your means of transportation to work? _______________________________________________________________
Driver’s licensenumber ____________________________ State of issue _______ __ Operator __ Commercial (CDL) __ Expiration date ______________________Have you had any accidents during the past three years? How many? ___________________Have you had any moving violations during the past three years?
How Many? ___________________
OFFICE ONLY__ Yes__ Yes Word__ Yes Typing__ No_____ WPM 10-key __ NoProcessing__ No_____ WPMPersonal __ Yes __ PC Computer__ No__ Mac Other
Skills ______________________________________________
Please list two references other than relatives or previous employers.
Name ____________________________________________
Name _____________________________________________
Position ___________________________________________
Position ___________________________________________
Company _________________________________________
Company __________________________________________
Address ___________________________________________
Address___________________________________________
Telephone (____________ )Telephone (___________ )An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.
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Page 3
PLEASE PRINT ALL INFORMATION REQUESTED.
MILITARY HAVE YOU EVER BEEN IN THE ARMED FORCES?__ Yes __ No
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?__ Yes __ No
Specialty ___________________________________ Date Entered ________________ Discharge Date ______________Work Experience Please list your work experience for the past five years beginning with your most recent job held.If you were self-employed, give firm name. Attach additional sheets if necessary.
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Page 4
SIGNATURE OF APPLICATION ______________________________________
