2221 State Road 175, Richfield WI 53076
info@gillitzerelectric.net
(262) 251-1790
Providing Quality Electrical Services in Southeastern Wisconsin
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PERSONAL INFORMATION
Name
*
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Last
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ZIP Code
Permanent Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone No.
*
Secondary Phone No.
Email
*
Referred By
EMPLOYMENT DESIRED
Position
*
Date You Can Start
*
MM slash DD slash YYYY
Are you employed now?
*
yes
no
If so, may we inquire of your present employer?
yes
no
Ever applied to this company before?
*
yes
no
Where?
When?
EDUCATION HISTORY
High School
Address
Years Attended
Did you graduate?
yes
no
Subjects Studied
College
Address
Years Attended
Did you graduate?
yes
no
Subjects Studied
Trade, Business or Correspondence School
Address
Years Attended
Did you graduate?
yes
no
Subjects Studied
GENERAL INFORMATION
Subject of Special Study/Research Work
Special Training
Special Skills
US Military or Naval Service
Rank
FORMER EMPLOYERS
LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST
Dates of Employment
*
Mo/Yr
Employer
*
Address
*
Salary
*
Position
*
Reason for Leaving
*
Dates of Employment
Mo/Yr
Employer
Address
Salary
Position
Reason for Leaving
Dates of Employment
Mo/Yr
Employer
Address
Salary
Position
Reason for Leaving
Dates of Employment
Mo/Yr
Employer
Address
Salary
Position
Reason for Leaving
REFERENCES
GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.
Name
*
Address
Phone
*
Business/Relationship
*
Years Known
*
Name
*
Address
Phone
*
Business/Relationship
*
Years Known
*
Name
*
Address
Phone
*
Business/Relationship
*
Years Known
*
AUTHORIZATION
Authorization
*
I have read, understand, and agree with the following:
“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 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.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.”
In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.
Name
First
Last
By checking this box, I acknowledge my electronic signature
Date
MM slash DD slash YYYY