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Printable Job Application

Application for Employment

Please fill out form completely for employment consideration. Print and fax or mail when

Prospective employees will receive consideration without discrimination because of race, creed,
color, sex, age, national origin or handicap. We are an equal opportunity employer.
Personal Information
Last Name First Middle Date
Harris Lindy Sue Marie January 9, 2018
Street Address Home Phone
( )
408 5th St. North (641) 381 - xxxx
City, State, Zip

Northwood, Iowa, 50459

Business Phone Email Address:
( ) -
What was your previous address? How long at present

_________ Years
N/A ________
N/A Months
Are you over 18 years of age? Yes No How long at present
If not, employment is subject to verification of minimum legal age. address?

_________ Years
2 Months
Have you ever applied for employment with us? Social Security No.
Yes No
If Yes: Month and Year__________ Location______________________________ xxx - xx - xxxx

How did you learn of our organization?

I learned of this through a working employee of this organization.

Are you legally eligible for employment in the United States? When will you be able to work?

Any select date


Are you employed now? If so, may we inquire of your present employer?
Yes Yes

Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary
offenses, which has not been annulled, expunged or sealed by a court? Yes No If
Yes, describe in full. (1 of 4) [5/11/2003 12:35:01]

Printable Job Application

Are there any reasons for which you might not be able to perform the job duties (with a
reasonable accommodation)?
Yes No If Yes, please explain.

Drivers License# State Any Violations?



No. of
Course of Did you Degree or
School Name and location of school years
study graduate? diploma
College Yes
N/A N/A N/A No N/A
High Yes
Northwood-Kensett Jr/Sr High 3.5 years No May 2018
Trade Yes
School N/A N/A N/A No N/A
Other Yes
N/A N/A N/A No N/A

Complete this section if you served in the U.S. Armed Forces Branch of Service

Describe your duties and any special training Period of Active Duty (Month & Year)

From N/A To N/A

Rank at Discharge N/A
Date of Final Discharge

Employment History Please give accurate, complete full-time and part-time employment
record. Start with present or most recent employer.

Company Name Telephone

Mills Fleet Farm (641 ) 423 -4474
Address Employed (Start Month and Year)
3200 - 4th Street SW Mason City, IA 50401 From October 2017 To 2018
Name of Supervisor Hourly Rate
Weekdays - $8.25 Weekdays - $8.25
Nichole Start Weekends - $10.50 Last Weekends - $10.50
Start Job Title and Describe Your Work Reason for Leaving
Cashier. Scan customers items and complete transactions. Still employed (2 of 4) [5/11/2003 12:35:01]

Printable Job Application

Company Name Telephone

Tequila’s Bar and Grill (641 ) 323 -0000
Address Employed (Start Month and Year)

846 Central Ave, Northwood, IA 50459

From February 2016 To September 2017
Name of Supervisor Hourly Rate
Hostess - $8.25 Hostess - $8.25
Shawna Ramirez Start Waitress - $4.25 Last Waitress - $4.25
Start Job Title and Describe Your Work Reason for Leaving
Waitress. Took customer’s drink and food orders. Brought out food to customers, totaled thier bill, and completed their
transactions. Hostess. Sat customers, cleared off tabels, completed customer transactions.
Career Change
Company Name Telephone
Pioneer Seeds (641 )xxx - xxxx
Address Employed (Start Month and Year)

129 Industrial Drive, Forest City, IA, 50436 From July 2016 To August 2016
Name of Supervisor Hourly Rate

Bob Miller Start $8.00 Last $8.00

Start Job Title and Describe Your Work Reason for Leaving
Detassler. Picking tassels off of female corn. Seasonal position.
Company Name Telephone
City of Northwood (641 ) 324 - 1075
Address Employed (Start Month and Year)
May 2014; August 2014;
627 Central Ave. Northwood, IA, 50459 From May 2015 To August 2015
Name of Supervisor Hourly Rate

Dedra Harris Start $5.25 Last $5.25

Start Job Title and Describe Your Work Reason for Leaving
Concession stand. Prepare and sell concession stand items.
Basket House. Welcome people into the pool. Seasonal position.
Do not contact
We may contact the employers listed above
unless you indicate those you do not want us to Employer Number(s)_____________________
contact. Reason____________________________

References: Give below the names of three persons not related to you, whom you have known at
least one year.
Name Address Business
Brooke Hepperly 1724 430th St. Northwood, IA, 50459 Mercy 10 years
Kelli Dorsey 3938 Finch Ave. Hanlontown, IA, 50444 Mercy 9 years
Mary Songstad 910 10th Ave. N, Northwood, IA, 50459 N/A 18 years (3 of 4) [5/11/2003 12:35:01]

Printable Job Application

The information provided in this Application for Employment is true, correct and complete. If
employed, any misstatements 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 an 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 and address of the agency so I
may obtain from them the nature and substance of the information contained in the report.

January 9, 2018 _________________________________
Date Signature

Please complete and mail or fax a copy of this form to:

Environmental Recycling
Attn: Human Resources
PO Box 167, Bowling Green, Ohio 43402
Phone (419) 354-6110
Fax (419) 354-5110 (4 of 4) [5/11/2003 12:35:01]