Application Form

Application for Employment at Portzen Construction

205 Stone Valley, Dr., Dubuque, IA 52003 (563)557-7642

*Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, handicap or veteran status

Personal

Last Name (required)

First Name (required)

MI

Street Address (required)

City, State, Zip (required)

Phone Number (required)

Have you ever applied for employment with us?(required)
YesNo
If yes, month and year:

Position Desired (required)

Weekly Pay Expected $

Apart from absence for religious observance, are you available for full-time work? (required)
YesNo
If not, what hours can you work?

Will you work overtime if asked? (required)
YesNo
Are you legally eligible for employment in the United States (required)
YesNo
Date Available to Start Work (required)

Other Special Training or Skills (Machine Operation, Driver's license, etc.) (required)

Are you over 18 years of age? (required)
YesNo
If you belong to a union, Enter the union here:

Education

	Name and Location of School	Course of Study	No. of Years Completed	Did you Graduate?	Degree or Diploma
College/Business/Trade/Technical				YesNo
High School				YesNo
Elementary				YesNo

Military

Did you serve in the U.S. Armed Forces?	If "Yes", in what Branch?	Describe any training received relevant to the position for which you are applying.
YesNo

Employment

*Start with your present or most recent employer.

1. Company Name	Telephone
Address	Employed (Month and Year) Weekly Pay From: To: Start: Last:
Name of Supervisor	Reason for Leaving
State Job Title and Discribe your Work

2. Company Name	Telephone
Address	Employed (Month and Year) Weekly Pay From: To: Start: Last:
Name of Supervisor	Reason for Leaving
State Job Title and Discribe your Work

3. Company Name	Telephone
Address	Employed (Month and Year) Weekly Pay From: To: Start: Last:
Name of Supervisor	Reason for Leaving
State Job Title and Discribe your Work

4. Company Name	Telephone
Address	Employed (Month and Year) Weekly Pay From: To: Start: Last:
Name of Supervisor	Reason for Leaving
State Job Title and Discribe your Work

State name of relatives and friends working for us.

May we ask these people about you?
YesNo

References

Person	Business	Phone
1.
2.
3.
4.

Signature

The information provided in this Application from Employment is true, correct, and complete. if employed, any misstatement or omissions of fact on this application may result in my dismissal.

I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future.

If you decide to engage in investigative consumer-reporting agency to report on my credit and personal history I authorize you to do so. If a report is obtained you must provide, at my request, the name of the agency so I may obtain from them the nature and substance of the information contained in the report.

Date

Signature