Midway City Corporation

EMPLOYMENT APPLICATION

Please submit a current resume with your application

Name:

LastFirstM.I.

Address:

Street AddressCityStateZIP

Cell/Work Phone:Home Phone:

List the positions you are interested in by specific title (Example: Admin. Assistant, Public Works, Planning)

1st Choice:2nd Choice:

Available to work:Full-Time Part-Time Temporary

Date You Can Start:Salary Desired:

Are You Employed Now? Yes No If yes, may we contact your present employer? Yes No

______

Have You Applied to This Company Before?Yes NoWhere? ______When?______

List Any Trade or Professional Licenses,Certificates, or Registrations:

______

______

References: List Three Persons Not Related to You Whom You Have Known At Least One Year.

Name / Address / Telephone/Business/Occupation

Education:

High School Graduate? Yes No If No, Indicate Highest Grade completed (1-12)
College, Business or Trade Schools (Name and City Location) / Major or Vocational Subjects / Length of time Degree/Certificate

Convictions:

Have you ever been convicted of a misdemeanor or a felony? Yes No. If yes, explain:

Work History: Beginning with present or most recent, list your previous three employers. If you wish to elaborate, a supplemental sheet may be attached. Include military service, if applicable.

Firm Name:Dates of Employment:

Address:

Street AddressCityStateZIP

Job Title, Responsibilities and Duties:

Reason for Leaving:

Firm Name:Dates of Employment:

Address:

Street AddressCityStateZIP

Job Title, Responsibilities and Duties:

Reason for Leaving:

Firm Name:Dates of Employment:

Address:

Street AddressCityStateZIP

Job Title, Responsibilities and Duties:

Reason for Leaving:

Additional Qualifications and Skills: Software Applications,Machines, Equipment, Tools Used, Related Activities

A current DMV record must be submitted with all applications.

Certification of Applicant:

I certify that all statements made in this application are true and correct, and that any misstatement of material facts may subject me to disqualification or dismissal. Also, I authorize verification of all statements made in this application and authorize a background check to be done. If asked, I agree to furnish my Social Security number for purposes of doing the background check prior to an employment offer being made.

Signature:

Print Name: Date:

Revised August 2010