230 Hwy 1 & 92Washington, IA 52353Phone: 319-653-6235 | Fax: 319-653-6154
Are you 18 years or older?YesNo
Date you can start?
Are you employed now?
*If so, may we contact your present employer?
Have you ever applied here before?- If so, when?
Name & Location of School:
# of years attended
Did you graduate?YesNo
Last rate of pay
From (Month & Year)
To (Month & Year)
Reason for leaving
PERSONS NOT RELATED TO YOU
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)
Your application will not be processed unless you have read and signed the Authorization, Release and Certification.
"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."
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