Carter County Gazette
An Equal Opportunity Employer
PBG is an equal opportunity employer. This application will not be used for
limiting or excluding any applicant from consideration for employment on a
basis prohibited by local, state, or federal law. Applicants requiring reasonable
accommodation in the application and/or interview process should notify a
representative of the organization.
Please print and fill out all sections
Applicant Name
_____________________
Home Phone _______________________
Other ____________________________
Email Address _____________________
Current Address:
Number and street
How were you referred to Company?:___________________________
Position(s) applying for:________________________________
Are you applying for:
What days and hours are you
available for work?___________________________________________
If applying for temporary work, when will you
be available? ___________________________________________
If hired, on what date can you start working?
___ / ___ / ___
Can you work on the weekends? [ ] Y or [ ] N
Can you work evenings? [ ] Y or [ ] N
Are you available to work overtime? [ ] Y or
[ ] N
Salary desired:
$________________________________
Have you ever applied to /
worked for Company before? [ ] Y or [ ] N
If yes, please explain (include date): ________________________
Do you have any friends, relatives, or
acquaintances working for Company? [ ] Y or [ ] N
If yes, state name & relationship: ________________________________
If hired, would you have transportation
to/from work? [ ] Y or [ ] N
Are you over the age of 18? (If under 18,
hire is subject to verification of minimum legal age.) [ ] Y or [ ] N
If hired, would you be able to present
evidence of your
If hired, are you willing to submit to and
pass a controlled substance test? [ ] Y or [ ] N
Are you able to perform the essential
functions of the job for which you are applying, either with / without
reasonable accommodation? [ ] Y or [ ] N
If no, describe the functions that cannot be
performed
_____________________________________________________________
(Note: PBG Company complies with the
Have you ever been convicted of a criminal
offense (felony or misdemeanor)? [ ] Y or [ ] N
If yes, please describe the crime - state
nature of the crime(s), when and where convicted and disposition of the
case.________________________________________________________________
(Note: No applicant will be denied
employment solely on the grounds of conviction of a criminal offense. The date
of the offense, the nature of the offense, including any significant details
that affect the description of the event, and the surrounding circumstances and
the relevance of the offense to the position(s) applied for may, however, be
considered.)
High School:
School name:
School city, state, zip:________________________________
Number of years completed: _______________
Did you graduate? [ ] Y or [ ] N
Degree / diploma earned: _______________
College / University:
School name:
School city, state, zip:________________________________
Number of years completed: ________
Did you graduate? [ ] Y or [ ] N
Degree / diploma earned: __________________
Vocational School:
Name: ________________________
Address:______________________
City, state, zip:________________________________
Number of years completed: ________
Did you graduate? [ ] Y or [ ] N
Degree / diploma? : __________________
Military:
Branch: ________________________
Rank in Military:________________________
Total Years of Service: ________
Skills/duties: ________
Related details:________________________________
Do you speak, write or understand any foreign
languages? [ ] Y or [ ] N
If yes, describe which languages(s) and how
fluent of a speaker you consider yourself to be. ____________________
Do you have any other experience, training,
qualifications, or skills which you feel should be brought to our attention, in
the case that they make you especially suited for working with us?
[ ] Y or [ ] N
If yes, please explain
___________________________________________
Are you currently employed? [ ] Y or [ ] N
If you are currently employed, may we contact
your current employer? [ ] Y or [ ] N
Below, please describe past and present
employment positions, dating back five years. Please account for all periods of
unemployment. Even if you have attached a resume, this section must be
completed.
Name of Employer:______________________________________
Name of Supervisor:____________________________________
Telephone Number:______________________________________
Business Type:[ ________________________
Address:
Length of Employment (Include Dates):
_____________________
Position & Duties:_______________________________________________________
Reason for Leaving:
_____________________________________________________________
May we contact this employer for references? [ ] Y or [ ] N
Name of Employer:______________________________________
Name of Supervisor:____________________________________
Telephone Number:______________________________________
Business Type: ________________________
Address:________________________
City, state, zip:________________________________
Length of Employment (Include Dates):
_____________________
Position & Duties:_______________________________________________________
Reason for Leaving: _____________________________________________________________
May we contact this employer for references? [ ] Y or [ ] N
Name of Employer:______________________________________
Name of Supervisor:____________________________________
Telephone Number:______________________________________
Business Type: ________________________
Address:________________________
City, state, zip:________________________________
Length of Employment (Include Dates):
_____________________
Position & Duties:_______________________________________________________
Reason for Leaving:
_____________________________________________________________
May we contact this employer for references? [ ] Y or [ ] N
List below three people who
have knowledge of your work performance within the last four years; please
include professional references only
Name - First, Last:
______________________________________
Telephone Number:____________________________
Address:
Occupation: ______________________________________
Number of Years Acquainted: ______________________________________
Name - First, Last:
______________________________________
Telephone Number:____________________________
Address:
Occupation: ______________________________________
Number of Years Acquainted: ______________________________________
Name - First, Last:
______________________________________
Telephone Number:____________________________
Address:
Occupation: ______________________________________
Number of Years Acquainted: ______________________________________
I certify that I have not
purposely withheld any information that might adversely affect my chances for
hiring. I attest to the fact that the answers given by me are true &
correct to the best of my knowledge and ability. I understand that any omission
(including any misstatement) of material fact on this application or on any
document used to secure can be grounds for rejection of application or, if I am
employed by this company, terms for my immediate expulsion from the company.
_____
I understand that if I am employed, my
employment is not definite and can be terminated at any time either with or
without prior notice, and by either me or the company.
_____
I permit the company to examine my
references, record of employment, education record, and any other information I
have provided. I authorize the references I have listed to disclose any
information related to my work record and my professional experiences with
them, without giving me prior notice of such disclosure. In addition, I release
the company, my former employers & all other persons, corporations,
partnerships & associations from any & all claims, demands or
liabilities arising out of or in any way related to such examination or
revelation.
Applicant's Signature:______________________________
Date:_________________________________