Bierlein Companies — Employment Application

To the Applicant: We appreciate your interest in our Firm and assure you that we are interested in your qualifications. A clear understanding of your background and work history will aid us in seeking to place you in a position which, in our judgment, best meets your qualifications. We are an equal opportunity employer and will not unlawfully discriminate on the basis of race, color, sex, religion, national origin, age, marital or veteran status, the presence of a medical condition or handicap, height, weight or any other protected status.
PERSONAL INFORMATION
Date of Application
First Name *
Last Name *
Address: *
Telephone Number (XXX-XXX-XXXX) *
E-mail: *
18 years of age or older? *	Yes No
Are you a US citizen? *	Yes No
Authorized to work in the United States? *	Yes No
Previously employed by Bierlein? *	Yes No
If yes, date(s) and supervisor name(s)
Have you filed an application before?	Yes No
If yes, date(s)
List any friends or relatives currently working at Bierlein
What method of transportation will you use to get to work?
EMPLOYMENT DESIRED
Position(s) you are applying for *
Kind of work sought *	Full Time Part Time
Do you have any additional special training, skills, qualifications or other experiences that relate to the position(s) that you are applying for?
Salary desired
When can you start?

EMPLOYMENT EXPERIENCE
List current or most recent job first
EMPLOYER ONE NAME *
Address *
Supervisor or Contact Name *
Phone Number (XXX-XXX-XXXX) *
Date(s) of employment *
Positions Held/Work Performed *
Ending Salary/Hourly Rate *

If no employer information, please enter N/A
EMPLOYER TWO NAME *
Address *
Supervisor or Contact Name *
Phone Number (XXX-XXX-XXXX) *
Positions Held/Work Performed *
Ending Salary/Hourly Rate *

If no employer information, please enter N/A
EMPLOYER THREE NAME *
Address *
Supervisor or Contact Name *
Phone Number (XXX-XXX-XXXX) *
Positions Held/Work Performed *
Ending Salary/Hourly Rate *

EDUCATION
List name and location of institution and years completed
Elementary
High School *
Did you receive...	Diploma GED
College/Grad School
Course of Study
Vocational/Training
Any other education/training?

MILITARY SERVICE RECORD
Have you been a member of the Armed Forces of the United State or State National Guard?	Yes No
If yes, what branch?
Rank at discharge
Date of discharge
Are you in the reserves?	Yes No
If yes, date obligation ends
Please list any special/technical training

ADDITIONAL INFORMATION
Have you been convicted of a crime? *	Yes No
If yes, where, when and nature of offense
Do you have a valid driver's license? *	Yes No
List names of professional, business or civic organizations or activities and any titles held
Please do not include any groups whose name or character would indicate discrimination based on race, color, religion, sex, national origin, handicap, marital or veteran status, height, weight or age.
State any additional information that you feel may be helpful to us in considering your application
Emergency contact name address and phone number
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