Utah Careers

PERSONAL INFORMATION

POSITION(S) APPLIED FOR *

Location *

Herriman, Utah Clearfield, Utah

DATE OF APPLICATION *

HOW DID YOU LEARN ABOUT US?

ADVERTISEMENT FRIEND WALK-IN EMPLOYMENT AGENCY RELATIVE OTHER

FIRST NAME

MIDDLE NAME

LAST NAME

HOME ADDRESS

CITY

STATE

ZIP CODE

HOME PHONE

CELL PHONE

CAN YOU PRODUCE THE DOCUMENTS NECESSARY TO VERIFY THAT YOU ARE A CITIZEN OF THE U.S. OR AN ALIEN AUTHORIZED FOR EMPLOYMENT IN THE U.S.?

YES NO

HAVE YOU EVER FILED AN APPLICATION WITH US BEFORE?

YES NO

ARE YOU CURRENTLY EMPLOYED?

YES NO

MAY WE CONTACT YOUR PRESENT EMPLOYER?

YES NO

ON WHAT DATE WOULD YOU BE AVAILABLE FOR WORK?

ARE YOU AVAILABLE TO WORK

FULL TIME PART TIME SHIFT WORK TEMP

DESIRED SALARY

ARE YOU CURRENTLY ON "LAY-OFF" STATUS AND SUBJECT TO RECALL?

YES NO

HAVE YOU BEEN CONVICTED OF A FELONY WITHIN THE LAST 7 YEARS? (Conviction will not necessarily disqualify an applicant from employment)

YES NO

REFERENCES

NAME

PHONE NUMBER

BUSINESS

YEARS KNOWN

EDUCATION - HIGH SCHOOL

SCHOOL NAME AND COMPLETION YEARS COMPLETED

YEAR GRADUATED

DIPLOMA/DEGREE

YEARS COMPLETED

9 (FR) 10 (SOPH) 11 (JR) 12 (SR)

SUBJECTS OF SPECIAL STUDY

College/Special

SCHOOL NAME AND COMPLETION

YEAR GRADUATED

DIPLOMA/DEGREE

YEARS COMPLETED

1 2 3 4

SUBJECTS OF SPECIAL STUDY

Graduate

SCHOOL NAME AND COMPLETION YEARS COMPLETED

YEAR GRADUATED

DIPLOMA/DEGREE

ACTIVITIES: CIVIT. ATHLETIC, ETC.

YEARS COMPLETED

1 2 3 4

SUBJECTS OF SPECIAL STUDY

EMPLOYMENT EXPERIENCE - List below last three employers beginning with your present job.

EMPLOYER

TELEPHONE NUMBER(S)

ADDRESS

REASON FOR LEAVING

EMPLOYED FROM

EMPLOYED TO

STARTING SALARY

FINAL SALARY

SUPERVISOR

WORK PERFORMED

EMPLOYER

TELEPHONE NUMBER(S)

ADDRESS

REASON FOR LEAVING

EMPLOYED FROM

EMPLOYED TO

STARTING SALARY

FINAL SALARY

SUPERVISOR

WORK PERFORMED

EMPLOYER

TELEPHONE NUMBER(S)

ADDRESS

REASON FOR LEAVING

EMPLOYED FROM

EMPLOYED TO

STARTING SALARY

FINAL SALARY

SUPERVISOR

WORK PERFORMED

IN CASE OF EMERGENCY NOTIFY:

NAME

ADDRESS

TELEPHONE NUMBER

The essential functions of the position for which you have applied include:

Lifting 50 pounds
Standing on your feet for 8 hours
Getting on your knees to mop floor
Bending and twisting your body
Controlling your bladder
Reaction to heat or cold
Creating Conversation with customers
Concentration
Lifting arms over head
Operating a cash register

CAN YOU PERFORM THE ABOVE FUNCTION OF THE JOB WITH OR WITHOUT ACCOMODATIONS?

YES NO

UPLOAD RESUME OR OTHER DOCUMENTS

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, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.

DATE

SIGNATURE

CHECK THIS BOX TO PROVE YOU'RE HUMAN

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