Personal Information
Last Name
*
First Name
*
SSN
Phone Number
Email Address
Present Address
*
:
Apt No:
City
*
:
State
*
:
Zip
*
:
Permanent Address:
Apt No:
City:
State:
Zip:
Are You 18 Years or Older?
Yes
No
Desired Employment
Position Applying For
Date You Can Start
Rate Of Pay Desired
Are you employed now?
Yes
No
If so, may we inquire of your present employer?
Yes
No
Have you ever applied to Schrock before?
Yes
No
Where?
Lincoln
Omaha
When?
Have you ever worked for Schrock before?
Yes
No
Where?
Lincoln
Crete
When?
Reason for Leaving:
Name of Last Supervisor at Schrock:
Who Referred you to Schrock?
Employment Agency
Newspaper Advertising
Friend
Internet Ad
State Employment Office
College Placement Service
Walk In
Other
Education
School Level
Name and Location of School
No. of Years Attend
Did You Graduate?
Subjects Studied
Middle School
High School
College
Trade, Business Or
Correspondence School
Other
General
Subjects of Special Study or Research Work:
Special Training:
Special Skills:
Former Employers
List below last five employers, starting with the most recent
Employer One
Name of Present or Last Employer:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Rate of Pay:
Weekly Final Rate of Pay:
May We Contact Your Supervisor?
Yes
No
Name of Supervisor:
Title:
Phone:
Email:
Description of Work:
Reason for Leaving:
Employer Two
Name of Previous Employer:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Rate Of Pay:
Weekly Final Rate of Pay:
May We Contact Your Supervisor?
Yes
No
Name of Supervisor:
Title:
Phone:
Email:
Description of Work:
Reason for Leaving:
Employer Three
Name of Previous Employer:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Rate Of Pay:
Weekly Final Rate of Pay:
May We Contact Your Supervisor?
Yes
No
Name Of Supervisor:
Title:
Phone:
Email:
Description of Work:
Reason for Leaving:
Employer Four
Name of Previous Employer:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Rate of Pay:
Weekly Final Rate of Pay:
May We Contact Your Supervisor?
Yes
No
Name of Supervisor:
Title:
Phone:
Email:
Description of Work:
Reason for Leaving:
Employer Five
Name of Previous Employer:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Rate of Pay:
Weekly Final Rate of Pay:
May We Contact Your Supervisor?
Yes
No
Name of Supervisor:
Title:
Phone:
Email:
Description of Work:
Reason for Leaving:
References
Name
Email/Phone
Business
Years
Acquainted
How You
Know Them
Service Record
Branch of Service:
Discharge Date Rank:
Have You Ever Been Convicted of a Felony?
Yes
No
If yes, explain. (will not necessarily exclude you from consideration):
Authorization
"I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FASIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.
I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE."
I Approve A DMV Check
License Number:
State:
DOB:
