Employment Application for Mid-South Steam Boiler & Engineering Co., Inc.

Please complete the entire employment application before submitting:

First Name:
Middle Initial:
Last Name:
Present Address Line 1:
Present Address Line 2:
Present City:
Present State:
Present Zip Code:
Permanent Address Line 1:
Permanent Address Line 2:
Permanent City:
Permanent State:
Permanent Zip Code:
Are you over 18?
Phone:	* required
Email Address:
Desired Employment:
Desired Position	* required
Date You Can Start :
Desired Salary:
Are You Employed Now:
If so, may we inquire of your present employer:
Ever apply to this company before:
Where?
When?:
Ever work for this company before :
Where?
When?
Name of last Supervisor:
Who referred you to this company? :
Education:
High School
Name and location:
Number of years attended:
Did you graduate?
Subjects studied:
College
Name and location:
Number of years attended:
Did you graduate?
Subjects studied:
Trade, Business or Correspondence School
Name and location:
Number of years attended:
Did you graduate?
Subjects studied:
General:
Subjects of Special Study or Research Work:
Special Training:
Special Skills:
Previous Employment Information:
Previous Employer 1 Company Name:
Previous Employer 1 City:
Previous Employer 1 State:
Zip Code :
Previous Employer 1 Contact:
Previous Employer 1 Employment Starting Date:
Previous Employer 1 Employment Leaving Date:
Previous Employer 1 Position Title:
Weekly Starting Salary :
Weekly Final Salary :
May we Contact Supervisor:
Previous Employer 1 Supervisor Name:
Previous Employer 1 Supervisor Title:
Previous Employer 1 Phone:
Description of Work:
Previous Employer 1 Reason For Leaving:

Previous Employer 2 Company Name:
Previous Employer 2 City:
Previous Employer 2 State:
Zip Code :
Previous Employer 2 Contact:
Previous Employer 2 Employment Starting Date:
Previous Employer 2 Employment Leaving Date:
Previous Employer 2 Position Title:
Weekly Starting Salary :
Weekly Final Salary :
May we Contact Supervisor:
Previous Employer 2 Supervisor Name:
Previous Employer 2 Supervisor Title:
Previous Employer 2 Phone:
Description of Work:
Previous Employer 2 Reason For Leaving:

Previous Employer 3 Company Name:
Previous Employer 3 City:
Previous Employer 3 State:
Zip Code :
Previous Employer 3 Contact:
Previous Employer 3 Employment Starting Date:
Previous Employer 3 Employment Leaving Date:
Previous Employer 3 Position Title:
Weekly Starting Salary :
Weekly Final Salary :
May we Contact Supervisor:
Previous Employer 3 Supervisor Name:
Previous Employer 3 Supervisor Title:
Previous Employer 3 Phone:
Description of Work:
Previous Employer 3 Reason For Leaving:
References: Give the names of three persons you are not related to whom you have known at least one year
Reference 1 Name:
Reference 1 Address::
Reference 1 Years Acquainted:
Reference 1 Business:
Reference 1 Phone:

Reference 2 Name:
Reference 2 Address::
Reference 2 Years Acquainted:
Reference 2 Business:
Reference 2 Phone:

Reference 3 Name:
Reference 3 Address::
Reference 3 Years Acquainted:
Reference 3 Business:
Reference 3 Phone:
Service Record:
Branch of Service Record :
Discharge Date :
Rank:

Have you ever been convicted of a felony?	* required
If yes, list felony charge:
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, 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.
Have you fully read the above Authorization::		YES

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