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656 Exchange Street, Suite 6
Middlebury, VT 05753-1522
Conveniently Located next to the Post Office Hub
 
 
 
 
 
 
 

Application For Employment

Date
Name
 
First Name
 
Last Name
 
Present Address
Address Line 1
Address Line 2
 
City
 
State
 
Zip
 
Phone No.
Secondary Phone No.
Referred By
Employment Desired
Position
Date you can start
Salary desired
Are you employed now?
If so, may we inquire of your present employer?
Are you legally authorized to work in the U.S.?
Ever applied to this company before?
Where
When
Education History
Name & Location of School
Years attended
Did you graduate
Subjects studied
 
College
Name & Location of School
Years attended
Did you graduate
Subjects studied
 
TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL
Name & Location of School
Years attended
Did you graduate
Subjects studied
General Information
Subject of special study/research work
Special training
Special skills
U.S. Military or Naval Service
Rank
Former Employers
(List below last four employers, starting with last on first)
 
Date (Month and Year)
 
From
 
To
 
Name and Address of Employer
Salary
Position
Reason for leaving
 
Date (Month and Year)
 
From
 
To
 
Name and Address of Employer
Salary
Position
Reason for leaving
 
Date (Month and Year)
 
From
 
To
 
Name and Address of Employer
Salary
Position
Reason for leaving
 
Date (Month and Year)
 
From
 
To
 
Name and Address of Employer
Salary
Position
Reason for leaving
References
(Give below the names of three persons not related to you, whom you have known at least one year)
 
Name
Address
Business
Years Known
 
Name
Address
Business
Years Known
 
Name
Address
Business
Years Known
Authorization
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."