(402) 694-2106
(800) 642-6795
PO Box 209
2225 Q Street
Aurora NE 68818

Application For Employment

Date
Name
Social Security No.
hidden
Address
City
State
Zip
Phone
Email
Position applied for
Special training or skills: (languages, machine operation, etc.) that would be of benefit in the job for which you are applying
Would you accept full-time work?
Would you accept part-time work?
On what date would you be available for work?
Have you ever been employed here before?
Do you have a legal right to be employed in the U.S.? (If yes, proof is required)
Are you of legal age to work?

Educational Background

High School:
Name and Location:
Course of Study:
Did you graduate?
Degree or Diploma:
Date
College:
Name and Location:
Course of Study:
Did you graduate?
Degree or Diploma
Date
Graduate School:
Name and Location:
Course of Study:
Did you graduate?
Degree or Diploma:
Date:
Vocational Training - Other:
Name and Location:
Course of Study:
Did you graduate?
Degree or Diploma:
Date:
Continuing Education:

Health

Do you have any impairment, physical, mental, or medical, which would require reasonable accommodations to perform the job for which you have applied:

General

Date and branch of military service:
Rank:
Present membership in National Guard or Reserves:
In what localities have you worked?
Who referred you?
List special interests or hobbies:
Activities (civil, athletic, fraternal, etc.) exclude organizations, the name and character which indicates sex, religion, race, color, or national origins of its members
Public speaking experience and/or training

Previous Employers and Addresses

List most recent employer first
1.
Company Name:
Contact:
Address:
Reason for leaving:
Date: -
Wage: -
Position:
2.
Company Name:
Contact:
Address:
Reason for leaving:
Date: -
Wage: -
Position:
3.
Company Name:
Contact:
Address:
Reason for leaving:
Date: -
Wage: -
Position:
4.
Company Name:
Contact:
Address:
Reason for leaving:
Date: -
Wage: -
Position:

References

1. Full Name:
Relationship to You:
City & State:
Phone Number:
2. Full Name:
Relationship to You:
City & State:
Phone Number:
3. Full Name:
Relationship to You:
City & State:
Phone Number:
4. Full Name:
Relationship to You:
City & State:
Phone Number:


This is to inform you that as part of our procedure for processing your application for employment, an investigative consumer report may be prepared whereby information is obtained concerning your character, general reputation, personal characteristics, and mode of living. You have the right to make a written request within a reasonable period of time to receive additional information about the nature and scope of this investigation.

I certify that the information provided in this application is complete and accurate and agree that concealment or falsification of any information is grounds for dismissal. You have my permission to contact schools, references, and past employers to verify any facts in establishing my qualifications.
Signature

Signature________________________________________________________________________

After completed mail to
Attn: HR
2225 Q Street
Aurora NE 68818
or email to hr@auroracoop.com


Job:
Time:
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