EVANS MANUFACTURING
4608 W 78th Avenue W
Rock Island, IL 61201
PH. (309) 787-3882 - FAX (309) 787-8344

APPLICATION FOR EMPLOYMENT

Personal Information

Date:            
Full Name:   
Address:       
City:                State: ZIP: 
Home Phone:   Cell Phone: 
Are you 18 years of age or older:  YES  NO
Are you a US Citizen or an alien authorized to work in the US? YES NO

Employment Desired

Position(s) Applying for: 
Date Available to Start:      Salary Desired: 
Currently Employed?  YES NO   
Shift Preference:  1st Choice 1st 2nd 3rd 2nd Choice 1st 2nd 3rd 3rd Choice 1st 2nd 3rd
Ever applied to this company before?  YES NO     When? 
Referred By:  
    Employee: 
    Illinois Skills Match
    Success Network Center
    Iowa Workforce Development
    QCEmployMe
    Newspaper Ad
    Other: 

FORMER EMPLOYERS (list last 3 employers, starting with most recent)

 #1          From:  To:
Company: 
Address: 
Contact:     Phone: 
May we Contact?  YES NO   Reason for Leaving:     
Position:    Salary: 
Job Duties:
 

  #2         From:  To:
Company: 
Address: 
Contact:     Phone: 
May we Contact?  YES NO   Reason for Leaving:     
Position:    Salary: 
Job Duties:
 

   #3        From:  To:
Company: 
Address: 
Contact:     Phone: 
May we Contact?  YES NO   Reason for Leaving:     
Position:    Salary: 
Job Duties:
 

Which of these jobs did you like best:  #1 #2 #3
What did you like most about this job?
 

EDUCATION

College/Trade School
Name:    
Address: 
Did you graduate?  YES NO   Year Attended:     
Subjects Studied:
 

College/Trade School
Name:    
Address: 
Did you graduate?  YES NO   Year Attended:     
Subjects Studied:
 

High School
Name:    
Address: 
Did you graduate?  YES NO   Year Attended:     
Subjects Studied:
 

GENERAL INFORMATION

Subjects of Special Study or Research:
 

Special Skills:
 

Activities (Civic, Athletic, Etc.):
Exclude Organizations, the Names of Which Indicates the Race, Creed, Sex, Age, Marital Status, Color or Nation of Origin of Its Members.
 

US Military or Naval Service: 
Rank:     Present Member in National Guard or Reserves? YES NO 

REFERENCES

Name:        Years Aquainted: 
Address: 
Phone:       May we Contact?  YES NO

Name:        Years Aquainted: 
Address: 
Phone:       May we Contact?  YES NO

Name:        Years Aquainted: 
Address: 
Phone:       May we Contact?  YES NO

DISCLOSURE

"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 this application shall be grounds for dismissal. 

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, and release all parties from all liability for any damage that may result in 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 prior notice and without cause."

Applicant Name: 

Signature:                                                                                                 
                    (To be signed at the time of interview/hire)