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?

    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

    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

    References

    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

    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)

    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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