EMPLOYMENT APPLICATION
A
S
Position Sought Maintenance Technician Full-Time ☒ Part-Time ☐
CANDIDATE INFORMATION A
Name Smith John A.
Last First Middle Initial
Address 123 Main Street Cedar Rapids, IA 52400
Street City, ST Zip Code
Phone 555-123-4567 E-mail john.smith@kirkwood.edu Social Security Number 555-00-1234 .
Are you able to perform the essential functions of this
position with or without accommodations?
Yes ☒ No ☐
Are you at least 18 years of age?
Yes ☒ No ☐
Are you legally eligible for employment in the U.S.?
Yes ☒ No ☐
Indicate your hours of availability in which you are
willing to work:
Any ☒ Mon ☐ Tues ☐ Wed ☐ Thu ☐ Fri ☐ Sat ☐ Sun ☐
All Hours ☐ Day Shift (7AM – 3PM) ☒
Afternoons (3PM – 11PM) ☒ Nights (11PM – 7AM) ☐
Have you ever been convicted of a crime (felony or
misdemeanor) other than a minor traffic violation?
This information may be considered in hiring or job placement,
but will not automatically disqualify you for employment.
Yes ☐ No ☒
If yes, please explain: N/A
___________________________________________
Are you willing and able to:
Work Overtime?
Yes ☒ No ☐
Work during holidays?
Yes ☐ No ☒
Provide a valid Driver’s License?
Yes ☒ No ☐
If Yes: Issuing State: Iowa Type: Driver’s
Endorsements: N/A
When will you be available to begin work?
2 weeks after offer of employment
Are you a veteran?
Yes ☐ No ☒
If yes, please list duty/specialized training:
N/A
___________________________________________
___________________________________________
EDUCATION A
School Name
& Location
Years
Completed
Field of Study
Did You
Graduate?
Degree/
Certificate/Diploma
High School
Cedar Rapids
High School
4 General Yes
High School
Diploma
College/University
Kirkwood
Community College
2 Industrial Maintenance Yes
A.A.S. Industrial
Maintenance
Additional
N/A N/A N/A N/A N/A
EMPLOYMENT HISTORY A
List your most recent employment first, followed by previous job experience(s). Use a separate sheet of paper if needed.
Employer Name & Address:
XYZ Warehouse Co
Cedar Rapids, IA
Job Title: Picker/Packer
Start Date:
07/2008
End Date:
Present
Duties:
Drive forklift, locate items in warehouse,
place orders on pallets for shipment.
Reason for Leaving:
N/A
Telephone:
555-987-6543
Pay: $10/hr
Supervisor:
Mike Greene
Employer Name & Address:
Hy-Vee
Omaha, NE
Job Title: Stocker (PT)
Start Date:
05/2006
End Date:
07/2008
Duties:
Placed items neatly on shelves, assisted
customers, and straightened aisles.
Reason for Leaving:
Moved to Cedar Rapids
Telephone:
555-012-3456
Pay: $6/hr
Supervisor: Tom Jones
Employer Name & Address:
N/A
Job Title: N/A
Start Date:
N/A
End Date:
N/A
Duties:
N/A
Reason for Leaving:
N/A
Telephone:
N/A
Pay: N/A Supervisor: N/A
SKILLS & QUALIFICATIONS A
Other qualifications such as special skills, abilities, or honors that should be considered, including types of computers,
software, and other equipment you are qualified to operate or repair:
Diagnostic and repair experience on engines, pneumatic tools, production machines, and motors.
Some knowledge of HVAC systems and basic electrical equipment. Forklift license.
Professional licenses, certifications, or registrations:
Certified Maintenance & Reliability Technician (CMRT), Society for Maintenance & Reliability Professionals May 2018
REFERENCES A
List three professional references:
Mike Greene Cedar Rapids, IA 555-987-2865 mgreene@xyzcorp.com Shift Supervisor 10
Name Address Telephone E-mail Occupation Years Known
Sherri Roberts Monticello, IA 555-987-2865 sherryroberts@gmail.com Manager (Hy-Vee) 12
Name Address Telephone E-mail Occupation Years Known
Russ Martinez Cedar Rapids, IA 555-987-1234 russm@kirkwood.edu Maintenance Professor 2
Name Address Telephone E-mail Occupation Years Known
NOTICE TO APPLICANT A
I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that falsified statements,
misrepresentations, or omissions may be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above to give any and all information concerning my previous
employment and any pertinent information they may have, personal or otherwise. I release all parties from all liability for any damage that may
result from furnishing this information to you. I understand that I may make a written request for information derived from background and
reference checks.
If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have
a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. If hired, employment is for no definite
period and may be terminated at any time without prior notice. I understand and agree to the information shown above.
John A. Smith 08/15/2018
Signature of Applicant Date
EMPLOYMENT APPLICATION
A
S
Position Sought _____________________________________________________ Full-Time ☐ Part-Time ☐
CANDIDATE INFORMATION A
Name _____________________________________________________________________________________
Last First Middle Initial
Address __________________________________________________________________________________
Street City, ST Zip Code
Phone _______________ E-mail ________________________ Social Security Number ________________.
Are you able to perform the essential functions of this
position with or without accommodations?
Yes ☐ No ☐
Are you at least 18 years of age?
Yes ☐ No ☐
Are you legally eligible for employment in the U.S.?
Yes ☐ No ☐
Indicate your hours of availability in which you are
willing to work:
Any ☐ Mon ☐ Tues ☐ Wed ☐ Thu ☐ Fri ☐ Sat ☐ Sun ☐
All Hours ☐ Day Shift (7AM – 3PM) ☐
Afternoons (3PM – 11PM) ☐ Nights (11PM – 7AM) ☐
Have you ever been convicted of a crime (felony or
misdemeanor) other than a minor traffic violation?
This information may be considered in hiring or job placement,
but will not automatically disqualify you for employment.
Yes ☐ No ☐
If yes, please explain: __________________________
___________________________________________
Are you willing and able to:
Work Overtime?
Yes ☐ No ☐
Work during holidays?
Yes ☐ No ☐
Provide a valid Driver’s License?
Yes ☐ No ☐
If Yes: Issuing State: _____ Type: _____________
Endorsements: ____________________________
When will you be available to begin work?
___________________________________________
Are you a veteran?
Yes ☐ No ☐
If yes, please list duty/specialized training:
___________________________________________
___________________________________________
___________________________________________
EDUCATION A
School Name
& Location
Years
Completed
Field of Study
Did You
Graduate?
Degree/
Certificate/Diploma
High School
College/University
Additional
EMPLOYMENT HISTORY A
List your most recent employment first, followed by previous job experience(s). Use a separate sheet of paper if needed.
Employer Name & Address:
Job Title:
Start Date:
End Date:
Duties:
Reason for Leaving:
Telephone:
Supervisor:
Employer Name & Address:
Job Title:
Start Date:
End Date:
Duties:
Reason for Leaving:
Telephone:
Supervisor:
Employer Name & Address:
Job Title:
Start Date:
End Date:
Duties:
Reason for Leaving:
Telephone:
Supervisor:
SKILLS & QUALIFICATIONS A
Other qualifications such as special skills, abilities, or honors that should be considered, including types of computers,
software, and other equipment you are qualified to operate or repair:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Professional licenses, certifications, or registrations:
__________________________________________________________________________________________________
REFERENCES A
List three professional references:
__________________________________________________________________________________________________
Name Address Telephone E-mail Occupation Years Known
__________________________________________________________________________________________________
Name Address Telephone E-mail Occupation Years Known
__________________________________________________________________________________________________
Name Address Telephone E-mail Occupation Years Known
NOTICE TO APPLICANT A
I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that falsified statements,
misrepresentations, or omissions may be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above to give any and all information concerning my previous
employment and any pertinent information they may have, personal or otherwise. I release all parties from all liability for any damage that may
result from furnishing this information to you. I understand that I may make a written request for information derived from background and
reference checks.
If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have
a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. If hired, employment is for no definite
period and may be terminated at any time without prior notice. I understand and agree to the information shown above.
__________________________________________________________________________________________________
Signature of Applicant Date