Miracles Electrical Contractors, Inc.

PERSONAL:

DATE:

Name:

Home Phone:

Last

First

Middle

Current Address:

Number

Street

City

State

Zip

S.S. #:

Are you over 18 yrs. old?       Yes       No

Driver’s License:

 Currently Valid                 Currently Invalid / Do Not Have One

Yr. Issued:________

State:

Number:

Type/Class:

Are you a citizen of the U.S., or do you have the legal right to be employed in the United States?

 Yes       No

Have you ever been convicted of any crime (excluding minor traffic violations) including DUI?  (Note the term “conviction” includes pleas of no contest)  Yes       No           If Yes, state the offense, location, date and disposition:

Who should be contacted in case of emergency?

Name

Relationship

Address

Phone Number

EMPLOYMENT DESIRED:

What type of work are you seeking?

  Full Time

  Part Time

  Temporary or Summer/Seasonal

Position applied for:

Salary Desired:

Date available to start:

Ever applied to our company before?

 Yes     No

Ever worked for our company before?

 Yes    No

If your answer to either above question was Yes, state when and where you applied and/or worked.

How did you learn of our company and/or position?

Are you now, or do you expect to be engaged in any other business or employment?

 Yes    No

Are there any days or hours you would be unable or unwilling to work?

 Yes    No

If Yes, please specify:

EDUCATION:

Name & Location

Dates

Graduate?

Courses Studied

High School

From:

Diploma/ Certificate    Yes      No

  Yes

To:

  No

College

From:

Diploma/ Certificate    Yes      No

  Yes

To:

  No

Trade School

From:

Diploma/ Certificate    Yes      No

  Yes

To:

  No

If you did not graduate, why did you leave high school or college?

Are you planning to pursue further studies?

  Yes      No

If Yes, when, where and what courses?

List any scholastic honors, offices held and activities during high school and college:

List and describe any other School or Specialized Training:

HEALTH:

Do you have any physical or mental defect or illness that may limit your ability to perform the particular job for which you are or applying, or which would prevent you from performing those functions in a manner which would not endanger your health and safety or the health and safety of others?   Yes      No

If the Response is Yes,  describe the nature and scope of reasonable accommodation which you believe would enable you to perform the essential functions of the job and/or perform these functions in a manner which would not endanger your health and safety or the health and safety of others.  Attach an additional sheet if necessary.

Date of last physical exam:

Results:

Have you ever been injured on the job?

  Yes      No

If Yes, please describe the injury:

Nature of Injury

Employer when Injured

Year

Cause of Injury

1.         

2.         

3.         

4.         

Will you abide by the safety rules of this company?

  Yes      No

Are you willing to take a physical exam and a drug screen at the company’s expense?

  Yes      No

Have you ever received treatment for alcohol or drug use?

  Yes      No

Have you used any illegal drug, including marijuana, in the last 12 months?

  Yes      No

Days lost to illness in the last two years due to illness:

Reason:

WORK HISTORY:

If you worked in any of your previous positions under another name, please give that name.

Are you presently employed?

  Yes      No

If Yes, may we contact your present employer?

  Yes      No

Have you ever filed an employment related lawsuit (excluding a worker’s compensation or unemployment benefit claim against a former employer?   Yes      No     If Yes, give details:

Please list the names of employers in consecutive order with present or most recent listed first.  Account for all periods of time including military service and any periods of unemployment.  If self-employed, give firm name and supply business references.

Name and Address of Employer

Name & Title of Last Supervisor

Dates Employed

Pay

From

Starting:

Month:

$

Year:

per

To

Ending

Month:

$

Year:

per

Telephone

Nature of Business:

Last Title:

Reason Leaving:

Duties:

Name and Address of Employer

Name & Title of Last Supervisor

Dates Employed

Pay

From

Starting:

Month:

$

Year:

per

To

Ending

Month:

$

Year:

per

Telephone

Nature of Business:

Last Title:

Reason Leaving:

Duties:

Name and Address of Employer

Name & Title of Last Supervisor

Dates Employed

Pay

From

Starting:

Month:

$

Year:

per

To

Ending

Month:

$

Year:

per

Telephone

Nature of Business:

Last Title:

Reason Leaving:

Duties:

Name and Address of Employer

Name & Title of Last Supervisor

Dates Employed

Pay

From

Starting:

Month:

$

Year:

per

To

Ending

Month:

$

Year:

per

Telephone

Nature of Business:

Last Title:

Reason Leaving:

Duties:

SPECIAL SKILLS:

Do you type?

  Yes      No     WPM:

Do you take Shorthand?

  Yes      No     WPM:

What languages do you speak fluently?

Please list any computer programs in which you are proficient, as well as the last date you used the program.

Program

Version

Windows or MAC?

Type, e.g. wp, d-base, etc.

Date Last Used

REFERENCES:

Give three references, not relatives or former employers:

Name

Address

Phone

Occupation

1.         

2.         

3.         

Applicant’s Signature

Date