If applicable, please upload your resumé.

E-mail Address
Date	Last Name	First Name	M.I.

Street Address

Apt /Unit #

City

State

Zip Code

Home Phone

Cell Phone

EMPLOYMENT DESIRED
Position applying for:	Date Available	Desired Salary
Are you seeking? Full-time Part-time Temporary work (summer or holiday) work

What days and hours are you available for work?

If applying for temporary work, what period of time will you be available?
From: To:

Are you available for work on weekends?
Yes
No

Would you be available to work overtime, if necessary?
Yes
No

Personal Information

Have you ever applied to or worked for Bejac Corporation before?

If yes, when?

Were you referred by anyone working for Bejac Corporation?
Yes
No

If yes, state name (only one) and relationship:
Name: Relationship:

Why are you applying for work at Bejac Corporation?

If hired, would you have a reliable means of transportation to and from work?

Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)
Yes
No

If hired, can you provide proof of eligibility to work in the U.S. legally?
Yes
No

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
Yes
No

If no, describe the functions that cannot be performed.

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and skills and agility tests.)

Have you ever been convicted of a crime, excluding traffic violation?
Yes
No

If Yes, please describe in full detail

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Have you ever been arrested but the case is pending/unresolved
Yes
No

If Yes, please describe in full detail

Note: Conviction of a crime is not an automatic bar to employment – all circumstances will be considered.

Have you received a DUI or DWI in the past 7 years? Yes No	Date of DUI or DWI
Are you currently employed? Yes No	If so, may we contact your current employer? Yes No

EDUCATION
High School	Address	Years Completed	Did you graduate? Yes No	Degree (if earned)
College	Address	Years Completed	Did you graduate? Yes No	Degree (if earned)
Other	Address	Years Completed	Did you graduate? Yes No	Degree (if earned)

Do you speak, write or understand any languages other than English?
Yes
No

If yes, which languages(s)?

Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at Bejac Corporation?
Yes
No

If so, please explain:

Answer the following questions if you are applying for a professional position:

Are you licensed / certified for the job applied for?
Yes
No

Name of license/certification:
Issuing state:
License/certification number

Has your license/certification ever been revoked or suspended?
Yes
No

If yes, state reason(s), date of revocation or suspension and date of reinstatement.

EMPLOYMENT HISTORY

List below all present and past employment starting with your most recent employer (last 10 years if applicable).
Account for all periods of unemployment. You must complete this section even if attaching a resume.

Employer	Phone
Address

Dates of Employment:
From

To

Supervisor

Job Title

Reason for Leaving

Responsibilities

Starting Salary

Ending Salary

May we contact this employer for a reference?
Yes
No

Employer	Phone
Address

Dates of Employment:
From

To

Supervisor

Job Title

Reason for Leaving

Responsibilities

Starting Salary

Ending Salary

May we contact this employer for a reference?
Yes
No

Employer	Phone
Address

Dates of Employment:
From

To

Supervisor

Job Title

Reason for Leaving

Responsibilities

Starting Salary

Ending Salary

May we contact this employer for a reference?
Yes
No

MILITARY
Have you obtained any special skills or abilities as the result of service in the military? Yes No
If Yes, please describe:

REFERENCE

List below three persons not related to you who have knowledge of your work performance within the last three years.

First Name	Last Name	Telephone No
Occupation	Relationship	Years Known

First Name	Last Name	Telephone No
Occupation	Relationship	Years Known

First Name	Last Name	Telephone No
Occupation	Relationship	Years Known

EMPLOYMENT DESIRED

Personal Information

EDUCATION

EMPLOYMENT HISTORY

MILITARY

REFERENCE