230 HIGHWAY 1 & 92 NORTH | WASHINGTON, IOWA 52353 | 800.327.3327

ENGINEERED BUILDING DESIGN L.C.

230 Hwy 1 & 92
Washington, IA 52353
Phone: 319-653-6235 | Fax: 319-653-6154

Personal Information

First Name:

Last Name:

Present Address

Permanent Address:

State

City:

Zip/Postal Code:

Phone #:

Are you 18 years or older?
YesNo

Employment Desired

Position:

Date you can start?

Salary desired?

Are you employed now?

*If so, may we contact your present employer?

Have you ever applied here before?
- If so, when?

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Education

Grammar School

Name & Location of School:

# of years attended

Did you graduate?
YesNo

Subjects Studied

High School

Name & Location of School:

# of years attended

Did you graduate?
YesNo

Subjects Studied

College

Name & Location of School:

# of years attended

Did you graduate?
YesNo

Subjects Studied

Trade School

Name & Location of School:

# of years attended

Did you graduate?
YesNo

Subjects Studied

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Former Employers

Employer 1

Employer

Supervisor

Duties

City/State

Phone

Last rate of pay

From (Month & Year)

To (Month & Year)

Reason for leaving

Employer 2

Employer

Supervisor

Duties

City/State

Phone

Last rate of pay

From (Month & Year)

To (Month & Year)

Reason for leaving

Employer 3

Employer

Supervisor

Duties

City/State

Phone

Last rate of pay

From (Month & Year)

To (Month & Year)

Reason for leaving

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PERSONS NOT RELATED TO YOU

Reference 1

First Name

Last Name

City/State

Phone

Business

Relationship

Reference 2

First Name

Last Name

City/State

Phone

Business

Relationship

Reference 3

First Name

Last Name

City/State

Phone

Business

Relationship

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PHYSICAL RECORD

Do you have any physical limitations that preclude you from performing any work for which you are being considered?
YesNo

If yes, what can be done to accommodate your limitations?(please describe)

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Authorization, Release and Certification

Your application will not be processed unless you have read and signed the Authorization, Release and Certification.

First Name:

Last Name:

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on the application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice."

Date

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