Application For Employment

You can either print, complete and mail this form to us, or complete the information and submit it online. All information will be kept completely confidential. * is a required field.
Personal Information
Name:
Social Security Number:
Are you 18 years or older?	Yes No
Present Address:
City:
State:
Zip Code:
Permanent Address:
City:
State:
Zip Code:
*Phone Number:
Desired Employment
Position:
Date you can start:
Salary Desired:
Are you employed now?	Yes No
If so, may we inquire of your present employer?	Yes No
Have you ever applied to this company before?	Yes No
Where?
When?
Have you ever worked for this company before?	Yes No
Where?
When?
Reason for leaving:
Name of last supervisor at this company:
Who referred you to this company?	Employment Agency Newspaper Advertising Friend State Employment Office College Placement Service Walk-in Other:
Education
Grammar School
Name and Location of School:
Number of Years Attended:
Did you graduate?	Yes No
Subjects Studied
High School
Name and Location of School:
Number of Years Attended:
Did you graduate?	Yes No
Subjects Studied:
College
Name and Location of School:
Number of Years Attended:
Did you graduate?	Yes No
Subjects Studied:
Trade, Business or Correspondence School
Name and Location of School:
Number of Years Attended:
Did you graduate::	Yes No
Subjects Studied:
General
Subjects of Special Study or Research Work:
Special Training:
Special Skills:
Please list below your last three employers, starting with the most recent one first.
Present or Last Employer
Present or Last Employer Name:
Address:
City:
State:
Zip Code:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Salary:
Weekly Final Salary:
May we contact your supervisor?	Yes No
Name of Supervisor:
Title:
Phone Number:
Description of Work:
Reason for leaving:
Previous Employer
Previous Employer Name:
Address:
City:
State:
Zip Code:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Salary:
Weekly Final Salary:
May we contact your supervisor?	Yes No
Name of Supervisor:
Title:
Phone Number:
Description of Work:
Reason for leaving:
Former Employer
Former Employer Name:
Address:
City:
State:
Zip Code:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Salary:
Weekly Final Salary:
May we contact your supervisor?	Yes No
Name of Supervisor:
Title:
Phone Number:
Description of Work:
Reason for leaving:
Below, give the names of three people you are not related to, whom you have known at least one year.
First Reference
Name:
Address:
Business:
Years Acquainted:
Second Reference
Name:
Address:
Business:
Years Acquainted:
Third Reference
Name:
Address:
Business:
Years Acquainted:
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."
Signature Verification
Dated today Sunday, 05-Sep-2010 03:10:06 CDT
*	By checking this box, I verify that all of the information that I've provided is correct. This is my online signature.

Professional Services Unlimited Inc.
PO Box 3581 Lawrence, KS 66046
Phone: 785-842-3301 • Toll Free 888-485-1927
Fax: 785-842-3340
Email: psuinc@sunflower.com