MLBC Application for Employment

Personal Information

Name

Date

Social Security Number

Present Address

Permanent Address

Phone

Referred By

Employment Desired

Position

Date You Can Start

Salary Desired

Are you currently employed?

If yes, may we inquire of your present employer?

Have you applied with BBC or MLBC before?

If yes, when?

Education

High School

Name of School

Location of School

Diploma?

Yes No

College

Name of School

Location of School

Diploma? Yes No

Years Attended

Subject(s) Studied

Trade, Business, or Correspondance School

Name of School

Location of School

Diploma? Yes No

Years Attended

Subject(s) Studied

General

Subjects of special study or research work

Do you speak any foreign languages fluently?

Yes No

If yes, what language(s)?

If yes, what other ways can you communicate in that language? Read Write

U.S. Military or Naval Service?

Yes No

Present Membership in National Guard or Preserves?

Yes No

Are you authorized to work in the U.S.?

Yes No

Have you ever been convicted of any criminal offense?

Yes No

If yes, please explain.

Former Employers

Please list below your last four employers, starting with the most recent first.

Dates

Name of Employer

Address of Employer

Salary

Position

Reason for Leaving

Dates

Name of Employer

Address of Employer

Salary

Position

Reason for Leaving

Dates

Name of Employer

Address of Employer

Salary

Position

Reason for Leaving

Dates

Name of Employer

Address of Employer

Salary

Position

Reason for Leaving

References

Give below the name of three persons, not related to you, whom you have know at least one year.

Name

Address

Business

Phone Number

Years Known

Name

Address

Business

Phone Number

Years Known

Name

Address

Business

Phone Number

Years Known

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may be terminated at any time without any previous notice.

Date

Signature

Interviewed by

MLBC Application for Employment

Description

Please Fix the Following