CERTIFICATION

PLEASE READ CAREFULLY BEFORE SIGNING

• I certify that the information contained in this application is true and correct. I understand that any false or misleading
statements or omissions regarding this application, whenever discovered, are grounds for disqualification for further
consideration or for dismissal from employment.
• If employed, I agree to conform to the guidelines and policies of Goodwill Contract Services Hawaii, Inc. I
understand that MY EMPLOYMENT IS AT-WILL AND CAN BE TERMINATED AT ANY TIME AND FOR ANY
REASON WITH OR WITHOUT ADVANCE NOTICE.
• I understand and agree that only the President/CEO of Goodwill Contract Services Hawaii, Inc. has any authority to
enter into any agreement to employ me for any specified period of time or to modify terms and conditions of my
employment. I agree that such an agreement must be in writing and signed by the President/CEO, and I will not rely
upon anything else.
2610 Kilihau Street
Honolulu, Hawaii 96819
Phone: (808) 836-0313 Fax: (808) 839-7322
INSTRUCTIONS: Thank you for your interest in our company. Please complete all portions of this employment application to be considered
for employment. If you require accommodation during the employment application process, including assistance in the completion of this
employment application, please let us know. We are an equal opportunity employer. We do not discriminate on the basis of age, race, sex,
religion, color, national origin, ancestry, marital status, disability, sexual orientation, arrest and court record or any other protected category
recognized by state and federal laws. This employment application is valid for a three-month period after submission to the Company and only
for the desired position.

• I understand and agree that Goodwill Contract Services Hawaii, Inc. may make a full and complete investigation of PERSONAL INFORMATION
my personal or employment history, and authorize any former employer, person, firm, corporation, school, LAST NAME FIRST NAME M.I. SOCIAL SECURITY NO.
government agency, or other entity to provide the Company with any information (including fact or opinion) they may
have regarding me. In consideration of the Company's review of this application, I release the Company and all PRESENT ADDRESS CITY, STATE, ZIP

providers of any information from any liability which may arise from a violation of the Fair Credit Reporting Act
(“FCRA”). I understand and agree that if offered employment by the Company, any such employment offer shall be DO YOU MEET THE MINIMUM AGE REQUIREMENT SET BY LAW PHONE CAN YOU, AFTER EMPLOYMENT, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO
FOR THE DESIRED POSITION? WORK IN THE UNITED STATES?
dependent upon the receipt of satisfactory references as determined by the Company. If employed by the Company,
YES NO YES NO * NOTE: If offered employment you will be required to
I further authorize the Company to provide truthful information (including fact or opinion) regarding my employment submit documentation required by IRCA.
to any potential or future employer and release and waive any claims against the Company for truthfully
communicating any such information to a potential or future employer.
DESIRED EMPLOYMENT
• I understand and agree that I may be required to submit to drug testing and complete post-offer medical examination
DESIRED POSITION* DATE YOU CAN START SALARY DESIRED
as part of my application for employment. I also understand and agree that I may be required to submit to a
complete medical examination during my employment with the Company, provided that such examination is job-
related and consistent with business necessity. The cost of such examination will be paid by the Company. I ARE YOU EMPLOYED NOW? HAVE YOU BEEN PROVIDED WITH THE JOB DESCRIPTION OF THE DESIRED POSITION?
authorize the physician conducting the examination and any laboratory testing any specimen obtained by the YES NO YES NO
physician or collection site to disclose the results of the examination and the laboratory test to the Company in IF YOU HAVE BEEN PROVIDED WITH A JOB DESCRIPTION OF THE DESIRED POSITION, PLEASE ANSWER THE QUESTION: AFTER READING THE JOB DESCRIPTION, CAN YOU
accordance with state and / or federal laws. The Company will keep such results confidential and disclose the PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION WITH OR WITHOUT REASONABLE ACCOMMODATION?

results only to person(s) who need to know or where required by law. Also, I agree to fully cooperate and provide YES NO
the Company with any additional consent(s) and / or release(s) as required by the Company to investigate my HAVE YOU EVER APPLIED FOR EMPLOYMENT AT THIS WHERE? WHEN?
employment application. COMPANY BEFORE?

YES NO
• Goodwill Contract Services Hawaii, Inc. may inquire into and consider any criminal conviction record that you may WHO REFERRED YOU TO THIS COMPANY?
have after a conditional offer of employment is made to you. The company may withdraw a conditional employment
RELATIVE_______________________ EMPLOYMENT AGENCY NEWSPAPER ADVERTISEMENT FRIEND
offer if you have a criminal conviction record which bears a rational relationship to the duties and responsibilities of STATE EMPLOYMENT OFFICE COLLEGE PLACEMENT SERVICE WALK IN OTHER
the position for which you are applying. Any criminal conviction record that is more that 10 years old or that involves
Family Court matters will not be considered. APART FROM RELIGION OBSERVANCES, WILL YOU BE ABLE TO WORK ALL OTHER TIMES? YES NO

*NOTE: If hired, you will be required to perform work as required by the Company.
• I understand and agree that if offered employment by Goodwill Contract Services Hawaii, Inc., I may be required to
disclose military services information in accordance with law, and that any such employment offer shall be EDUCATION / TRAINING
dependent upon the receipt of a satisfactory military record as determined by the Company. HIGH SCHOOL UNDERGRADUATE OTHER
COLLEGE / UNIVERSITY

• I understand and agree that all of the foregoing terms and conditions will become part of my employment SCHOOL NAME & LOCATION
relationship with the Company if I am employed by the Company.
NO. OF YEARS ATTENDED

Authorization/Signature of applicant:__________________________________________________________________ DID YOU GRADUATE?

DIPLOMA / DEGREE
Date:_______________________________
DESCRIBE COURSE OF STUDY
 FORMER EMPLOYERS
NAME OF PRESENT
LIST BELOW YOUR LAST FOUR EMPLOYERS, STARTING WITH THE MOST RECENT ONE OR LAST EMPLOYER

FIRST. FOR EACH EMPLOYER, YOU MUST ANSWER ALL QUESTIONS. USE ADDITIONAL ADDRESS CITY STATE ZIP
PAPER IF NECESSARY.
STARTING DATE DATE LAST WORKED JOB TITLE

NAME OF PRESENT
OR LAST EMPLOYER
STARTING HOURLY RATE/MO. FINAL HOURLY RATE/MO. MAY WE CONTACT
SALARY SALARY YOUR SUPERVISOR? YES NO
ADDRESS CITY STATE ZIP
NAME OF SUPERVISOR SUPERVISOR’S TITLE SUPERVISOR’S PHONE NUMBER

STARTING DATE DATE LAST WORKED JOB TITLE

DESCRIPTION OF WORK
STARTING HOURLY RATE/MO. FINAL HOURLY RATE/MO. MAY WE CONTACT
SALARY SALARY YOUR SUPERVISOR? YES NO
REASON(S) FOR LEAVING
NAME OF SUPERVISOR SUPERVISOR’S TITLE SUPERVISOR’S PHONE NUMBER

DESCRIPTION OF WORK REFERENCES

GIVE THE NAMES OF THREE PERSONS YOU ARE NOT RELATED TO, WHOM YOU HAVE
REASON(S) FOR LEAVING
KNOWN AT LEAST ONE YEAR AND WHOM WE CAN CONTACT.
YEARS
NAME ADDRESS PHONE NUMBER
KNOWN

1
NAME OF PRESENT
OR LAST EMPLOYER
2
ADDRESS CITY STATE ZIP
3

STARTING DATE DATE LAST WORKED JOB TITLE

JOB SKILLS, QUALIFICATIONS AND EMPLOYMENT GAPS

STARTING HOURLY RATE/MO. FINAL HOURLY RATE/MO. MAY WE CONTACT
SALARY SALARY YOUR SUPERVISOR? YES NO SUMMARIZE YOUR JOB SKILLS, TRAINING AND/OR STUDY THAT ARE RELEVANT FOR
NAME OF SUPERVISOR SUPERVISOR’S TITLE SUPERVISOR’S PHONE NUMBER
THE DESIRED POSITION. ALSO, EXPLAIN ANY PERIODS THAT YOU WERE NOT
WORKING. USE ADDITIONAL PAPER IF NECESSARY.
DESCRIPTION OF WORK

REASON(S) FOR LEAVING

NAME OF PRESENT
OR LAST EMPLOYER

ADDRESS CITY STATE ZIP

STARTING DATE DATE LAST WORKED JOB TITLE

STARTING HOURLY RATE/MO. FINAL HOURLY RATE/MO. MAY WE CONTACT

SALARY SALARY YOUR SUPERVISOR? YES NO

NAME OF SUPERVISOR SUPERVISOR’S TITLE SUPERVISOR’S PHONE NUMBER

DESCRIPTION OF WORK

REASON(S) FOR LEAVING

 FORMER EMPLOYERS
NAME OF PRESENT
LIST BELOW YOUR LAST FOUR EMPLOYERS, STARTING WITH THE MOST RECENT ONE OR LAST EMPLOYER

FIRST. FOR EACH EMPLOYER, YOU MUST ANSWER ALL QUESTIONS. USE ADDITIONAL ADDRESS CITY STATE ZIP
PAPER IF NECESSARY.
STARTING DATE DATE LAST WORKED JOB TITLE

NAME OF PRESENT
OR LAST EMPLOYER
STARTING HOURLY RATE/MO. FINAL HOURLY RATE/MO. MAY WE CONTACT
SALARY SALARY YOUR SUPERVISOR? YES NO
ADDRESS CITY STATE ZIP
NAME OF SUPERVISOR SUPERVISOR’S TITLE SUPERVISOR’S PHONE NUMBER

STARTING DATE DATE LAST WORKED JOB TITLE

DESCRIPTION OF WORK
STARTING HOURLY RATE/MO. FINAL HOURLY RATE/MO. MAY WE CONTACT
SALARY SALARY YOUR SUPERVISOR? YES NO
REASON(S) FOR LEAVING
NAME OF SUPERVISOR SUPERVISOR’S TITLE SUPERVISOR’S PHONE NUMBER

DESCRIPTION OF WORK REFERENCES

GIVE THE NAMES OF THREE PERSONS YOU ARE NOT RELATED TO, WHOM YOU HAVE
REASON(S) FOR LEAVING
KNOWN AT LEAST ONE YEAR AND WHOM WE CAN CONTACT.
YEARS
NAME ADDRESS PHONE NUMBER
KNOWN

1
NAME OF PRESENT
OR LAST EMPLOYER
2
ADDRESS CITY STATE ZIP
3

STARTING DATE DATE LAST WORKED JOB TITLE

JOB SKILLS, QUALIFICATIONS AND EMPLOYMENT GAPS

STARTING HOURLY RATE/MO. FINAL HOURLY RATE/MO. MAY WE CONTACT
SALARY SALARY YOUR SUPERVISOR? YES NO SUMMARIZE YOUR JOB SKILLS, TRAINING AND/OR STUDY THAT ARE RELEVANT FOR
NAME OF SUPERVISOR SUPERVISOR’S TITLE SUPERVISOR’S PHONE NUMBER
THE DESIRED POSITION. ALSO, EXPLAIN ANY PERIODS THAT YOU WERE NOT
WORKING. USE ADDITIONAL PAPER IF NECESSARY.
DESCRIPTION OF WORK

REASON(S) FOR LEAVING

NAME OF PRESENT
OR LAST EMPLOYER

ADDRESS CITY STATE ZIP

STARTING DATE DATE LAST WORKED JOB TITLE

STARTING HOURLY RATE/MO. FINAL HOURLY RATE/MO. MAY WE CONTACT

SALARY SALARY YOUR SUPERVISOR? YES NO

NAME OF SUPERVISOR SUPERVISOR’S TITLE SUPERVISOR’S PHONE NUMBER

DESCRIPTION OF WORK

REASON(S) FOR LEAVING

 CERTIFICATION
PLEASE READ CAREFULLY BEFORE SIGNING

• I certify that the information contained in this application is true and correct. I understand that any false or misleading
statements or omissions regarding this application, whenever discovered, are grounds for disqualification for further
consideration or for dismissal from employment.
• If employed, I agree to conform to the guidelines and policies of Goodwill Contract Services Hawaii, Inc. I
understand that MY EMPLOYMENT IS AT-WILL AND CAN BE TERMINATED AT ANY TIME AND FOR ANY
REASON WITH OR WITHOUT ADVANCE NOTICE.
• I understand and agree that only the President/CEO of Goodwill Contract Services Hawaii, Inc. has any authority to
enter into any agreement to employ me for any specified period of time or to modify terms and conditions of my
employment. I agree that such an agreement must be in writing and signed by the President/CEO, and I will not rely
upon anything else.
2610 Kilihau Street
Honolulu, Hawaii 96819
Phone: (808) 836-0313 Fax: (808) 839-7322
INSTRUCTIONS: Thank you for your interest in our company. Please complete all portions of this employment application to be considered
for employment. If you require accommodation during the employment application process, including assistance in the completion of this
employment application, please let us know. We are an equal opportunity employer. We do not discriminate on the basis of age, race, sex,
religion, color, national origin, ancestry, marital status, disability, sexual orientation, arrest and court record or any other protected category
recognized by state and federal laws. This employment application is valid for a three-month period after submission to the Company and only
for the desired position.

• I understand and agree that Goodwill Contract Services Hawaii, Inc. may make a full and complete investigation of PERSONAL INFORMATION
my personal or employment history, and authorize any former employer, person, firm, corporation, school, LAST NAME FIRST NAME M.I. SOCIAL SECURITY NO.
government agency, or other entity to provide the Company with any information (including fact or opinion) they may
have regarding me. In consideration of the Company's review of this application, I release the Company and all PRESENT ADDRESS CITY, STATE, ZIP

providers of any information from any liability which may arise from a violation of the Fair Credit Reporting Act
(“FCRA”). I understand and agree that if offered employment by the Company, any such employment offer shall be DO YOU MEET THE MINIMUM AGE REQUIREMENT SET BY LAW PHONE CAN YOU, AFTER EMPLOYMENT, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO
FOR THE DESIRED POSITION? WORK IN THE UNITED STATES?
dependent upon the receipt of satisfactory references as determined by the Company. If employed by the Company,
YES NO YES NO * NOTE: If offered employment you will be required to
I further authorize the Company to provide truthful information (including fact or opinion) regarding my employment submit documentation required by IRCA.
to any potential or future employer and release and waive any claims against the Company for truthfully
communicating any such information to a potential or future employer.
DESIRED EMPLOYMENT
• I understand and agree that I may be required to submit to drug testing and complete post-offer medical examination
DESIRED POSITION* DATE YOU CAN START SALARY DESIRED
as part of my application for employment. I also understand and agree that I may be required to submit to a
complete medical examination during my employment with the Company, provided that such examination is job-
related and consistent with business necessity. The cost of such examination will be paid by the Company. I ARE YOU EMPLOYED NOW? HAVE YOU BEEN PROVIDED WITH THE JOB DESCRIPTION OF THE DESIRED POSITION?
authorize the physician conducting the examination and any laboratory testing any specimen obtained by the YES NO YES NO
physician or collection site to disclose the results of the examination and the laboratory test to the Company in IF YOU HAVE BEEN PROVIDED WITH A JOB DESCRIPTION OF THE DESIRED POSITION, PLEASE ANSWER THE QUESTION: AFTER READING THE JOB DESCRIPTION, CAN YOU
accordance with state and / or federal laws. The Company will keep such results confidential and disclose the PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION WITH OR WITHOUT REASONABLE ACCOMMODATION?

results only to person(s) who need to know or where required by law. Also, I agree to fully cooperate and provide YES NO
the Company with any additional consent(s) and / or release(s) as required by the Company to investigate my HAVE YOU EVER APPLIED FOR EMPLOYMENT AT THIS WHERE? WHEN?
employment application. COMPANY BEFORE?

YES NO
• Goodwill Contract Services Hawaii, Inc. may inquire into and consider any criminal conviction record that you may WHO REFERRED YOU TO THIS COMPANY?
have after a conditional offer of employment is made to you. The company may withdraw a conditional employment
RELATIVE_______________________ EMPLOYMENT AGENCY NEWSPAPER ADVERTISEMENT FRIEND
offer if you have a criminal conviction record which bears a rational relationship to the duties and responsibilities of STATE EMPLOYMENT OFFICE COLLEGE PLACEMENT SERVICE WALK IN OTHER
the position for which you are applying. Any criminal conviction record that is more that 10 years old or that involves
Family Court matters will not be considered. APART FROM RELIGION OBSERVANCES, WILL YOU BE ABLE TO WORK ALL OTHER TIMES? YES NO

*NOTE: If hired, you will be required to perform work as required by the Company.
• I understand and agree that if offered employment by Goodwill Contract Services Hawaii, Inc., I may be required to
disclose military services information in accordance with law, and that any such employment offer shall be EDUCATION / TRAINING
dependent upon the receipt of a satisfactory military record as determined by the Company. HIGH SCHOOL UNDERGRADUATE OTHER
COLLEGE / UNIVERSITY

• I understand and agree that all of the foregoing terms and conditions will become part of my employment SCHOOL NAME & LOCATION
relationship with the Company if I am employed by the Company.
NO. OF YEARS ATTENDED

Authorization/Signature of applicant:__________________________________________________________________ DID YOU GRADUATE?

DIPLOMA / DEGREE
Date:_______________________________
DESCRIBE COURSE OF STUDY
 Goodwill Industries of Hawaii, Inc./Goodwill Contract Services Hawaii, Inc.
AFFIRMATIVE ACTION SELF-IDENTIFICATION SURVEY

Goodwill is subject to certain governmental recordkeeping and reporting requirements for the administration of civil
rights laws and regulations. In order to comply with these laws, we invite applicants/employees to voluntarily self-
identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject
you to any adverse treatment. The information obtained will be kept confidential and may only be used in accor-
dance with the provisions of applicable laws, executive orders, and regulations, including those which require the
information to be summarized and reported to the federal government for civil rights enforcement. When reported,
data will not identify any specific individual.

Name:________________________________________ Date:_____/_____/_____

Job Title:______________________________________ Department:_____________________

SEX: ____Male _____Female

RACE: (Check all categories that apply)

_____ Caucasian (White, not Hispanic or Latino): A person having origins in any of the
original peoples of Europe, North Africa, or the Middle East.

_____ Black or African American (Not Hispanic or Latino): A person having origins in any
of the Black racial groups of Africa.

_____ Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, Central or South
American, or other Spanish culture or origin, regardless of race.

_____ American Indian or Alaskan Native (Not Hispanic or Latino): A person having origins
in any of the original peoples of North and South America (including Central America), and
maintain tribal affiliation or community attachment.

_____ Asian (Not Hispanic of Latino): A person having origins in any of the original peoples of the
Far East, Southeast Asia, the Indian Subcontinent, including for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Phillipine Islands, Thailand, and
Vietnam.

_____ Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins
in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

______ Hawaii

______ Guam

______ Samoa

______ Micronesia: Name of Island__________________________________________

______ Other Pacific Islander

_____ Two or More Races (Not Hispanic or Latino): All persons who identify with more than one
of the above races except Hispanic or Latino.
 Goodwill Industries of Hawaii, Inc./Goodwill Contract Services Hawaii, Inc.
AFFIRMATIVE ACTION SELF-IDENTIFICATION SURVEY

DISABILITY: (Check if applicable)

_____ Yes (Disabled): Any person who

(1) Has a physical or mental impairment which substantially limits one or more of
such person’s major life activities,

(2) Has a record of such impairment, or

(3) Is regarded as having such an impairment.

VETERANS STATUS: (Check if applicable)

_____ Vietnam Era Veteran: A person who

(1) Served on active duty for a period of more than 180 days, any part of which
Occurred between August 5, 1964 and May 7, 1975, and was discharged or
released with other than a dishonorable discharge, or

(2) Was discharged or released from active duty for a service-connected disability.

_____ Veteran: A person who

Served on active duty during a war or in a campaign or expedition for which a campaign
badge was authorized.
Goodwill Industries of Hawaii, Inc./GCSH
2610 Kilihau Street, Honolulu, HI 96819
Telephone: (808) 836-0313
Fax: (808) 839-7322

EMPLOYMENT VERIFICATION AND AUTHORIZATION RELEASE

To: Employer:___________________________________________________________________
Address:____________________________________________________________________
Telephone: ( )______________________________ Fax: ( )______________________

I have applied for employment with Goodwill Industries of Hawaii, Inc. I authorize you to release all information
below including any employment record, character, work habits, attendance and the reason for my leaving your
employment in the section below. I release you and your agents from any and all claims arising from your response
to this information. The following data may help in identifying my record. Thank you for your assistance in this
matter.

Applicant name: ____________________________ SS#:_____________________________

Position held: ______________________________ Dept: ____________________________
Immediate Supervisor:_______________________ Salary:_______________ Per:________
Dates of employment: From: ___/___/___ To:___/___/___
Applicants Signature:___________________________ Date: ___/___/___
TO BE COMPLETED BY PREVIOUS EMPLOYER
Position held: ______________________________ Dept:____________________________
Rate/Salary:________________________________ Per Hour/ Week/ Month/ Year
Dates of employment: From: ___/___/___ To:___/___/___
Discharged:____ Reasigned:____ Laid off: ____
Applicant’s reason for leaving:________________________________________________________
Would you rehire the applicant? Yes: ___ No:___
Please rate the applicant’s performance in the following areas:
What are the applicant’s strong points?______________________________________________________
What are the applicant’s weak points?_______________________________________________________
Above Average Average Below Average Comments
Attendance
Cooperation
Job Knowledge
Initiative
Productivity
Reliability
Quality of Work

Print Name:________________________________ Title:____________________________

Signature:_________________________________ Date: ___/___/___
Goodwill Industries of Hawaii, Inc./GCSH
2610 Kilihau Street, Honolulu, HI 96819
Telephone: (808) 836-0313
Fax: (808) 839-7322

EMPLOYMENT VERIFICATION AND AUTHORIZATION RELEASE

To: Employer:___________________________________________________________________
Address:____________________________________________________________________
Telephone: ( )______________________________ Fax: ( )______________________

I have applied for employment with Goodwill Industries of Hawaii, Inc. I authorize you to release all information
below including any employment record, character, work habits, attendance and the reason for my leaving your
employment in the section below. I release you and your agents from any and all claims arising from your response
to this information. The following data may help in identifying my record. Thank you for your assistance in this
matter.

Applicant name: ____________________________ SS#:_____________________________

Position held: ______________________________ Dept: ____________________________
Immediate Supervisor:_______________________ Salary:_______________ Per:________
Dates of employment: From: ___/___/___ To:___/___/___
Applicants Signature:___________________________ Date: ___/___/___
TO BE COMPLETED BY PREVIOUS EMPLOYER
Position held: ______________________________ Dept:____________________________
Rate/Salary:________________________________ Per Hour/ Week/ Month/ Year
Dates of employment: From: ___/___/___ To:___/___/___
Discharged:____ Reasigned:____ Laid off: ____
Applicant’s reason for leaving:________________________________________________________
Would you rehire the applicant? Yes: ___ No:___
Please rate the applicant’s performance in the following areas:
What are the applicant’s strong points?______________________________________________________
What are the applicant’s weak points?_______________________________________________________
Above Average Average Below Average Comments
Attendance
Cooperation
Job Knowledge
Initiative
Productivity
Reliability
Quality of Work

Print Name:________________________________
Title:____________________________Signature:_________________________________
Date: ___/___/___
Goodwill Industries of Hawaii, Inc./GCSH
2610 Kilihau Street, Honolulu, HI 96819
Telephone: (808) 836-0313
Fax: (808) 839-7322

EMPLOYMENT VERIFICATION AND AUTHORIZATION RELEASE

To: Employer:___________________________________________________________________
Address:____________________________________________________________________
Telephone: ( )______________________________ Fax: ( )______________________

I have applied for employment with Goodwill Industries of Hawaii, Inc. I authorize you to release all information
below including any employment record, character, work habits, attendance and the reason for my leaving your
employment in the section below. I release you and your agents from any and all claims arising from your response
to this information. The following data may help in identifying my record. Thank you for your assistance in this
matter.

Applicant name: ____________________________ SS#:_____________________________

Position held: ______________________________ Dept: ____________________________
Immediate Supervisor:_______________________ Salary:_______________ Per:________
Dates of employment: From: ___/___/___ To:___/___/___
Applicants Signature:___________________________ Date: ___/___/___
TO BE COMPLETED BY PREVIOUS EMPLOYER
Position held: ______________________________ Dept:____________________________
Rate/Salary:________________________________ Per Hour/ Week/ Month/ Year
Dates of employment: From: ___/___/___ To:___/___/___
Discharged:____ Reasigned:____ Laid off: ____
Applicant’s reason for leaving:________________________________________________________
Would you rehire the applicant? Yes: ___ No:___
Please rate the applicant’s performance in the following areas:
What are the applicant’s strong points?______________________________________________________
What are the applicant’s weak points?_______________________________________________________
Above Average Average Below Average Comments
Attendance
Cooperation
Job Knowledge
Initiative
Productivity
Reliability
Quality of Work

Print Name:________________________________ Title:____________________________

Signature:_________________________________ Date: ___/___/___