Employment Application

Fields marked with * are required.

Applicant Information

Last Name *

First Name *

M.I.

Date *

Street Address *

Apartment / Unit #

City *

State *

ZIP *

Phone *

Email Address *

Date Available *

Social Security No.

Desired Salary

Position Applied For *

Are you a U.S. Citizen? *

Yes No

If no, authorized to work in U.S.?

Yes No N/A

Previously worked for Western-EGI?

Yes No

If yes, when?

Ever convicted of a felony?

Yes No

If yes, explain

Education

High School

School Name

Address

From

Did you graduate?

Yes No

Degree / Diploma

College / University

School Name

Address

From

Did you graduate?

Yes No

Degree

Other Education / Training

Institution

Address

From

Did you graduate?

Yes No

Degree / Certificate

References

Please list three professional references.

Reference 1

Full Name

Relationship

Company

Phone

Address

Reference 2

Full Name

Relationship

Company

Phone

Address

Reference 3

Full Name

Relationship

Company

Phone

Address

Previous Employment

Employer 1

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact this supervisor?

Yes No

Employer 2

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact this supervisor?

Yes No

Employer 3

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact this supervisor?

Yes No

Military Service

Branch

From

Rank at Discharge

Type of Discharge

If other than honorable, explain

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Full Name (Electronic Signature) *

Date *

Equal Opportunity Employer

Western-EGI is an Equal Opportunity Employer. All employment decisions are based on qualifications, merit, and need.