Shield Card America Employment Application

Do you use tobacco in any form? Yes   No    If Yes, stop here and return form to SCA Personnel.

Please Print Clearly

Date of Application _________________
Position(s) Applied For __________________________________ Salary Desired: ______________
Referral Source:     Advertisement     Friend     Relative     Walk-In
  Workforce Services     Other ______________________________________
NAME _________________ _________________ ______________ ______|_____|_______
Last
First
Middle
Social Security Number
ADDRESS _________________________________________________  ___________________
Street
Apt/Number
__________________________________ ______________ ___________________
City
State
Zip Code
PHONE _________________ _________________
Home
Business
If you are under 18, can you furnish a work permit? Yes     No
Have you filed an application here before? Yes     No    If yes, give date ____________________
Have you ever been employed here before? Yes     No  If yes, give date ___________________
Are you employed now? Yes     No    May we contact your present employer? Yes     No
 
Are you prevented from lawfully becoming employed
in this country because of Visa or Immigration Status? Yes     No

(Proof of citizenship or immigration status may be required upon employment.)
 
On what date would you be available to work? ____________________
Are you available to work     Full Time     Part Time     Shift Work     Temporary
Are you on layoff and subject to recall? Yes     No

Can you travel if a job requires it? Yes     No
 
Have you been convicted of a felony within the last 7 years? No     Yes
(Conviction will not necessarily disqualify applicant from employment.)
If Yes, please explain _____________________________________________________________
_____________________________________________________________________________

Veteran of the U.S. Military service? Yes     No    If Yes, Branch ________________________


List professional, trade, business or civic activities and offices held.
(You may exclude those which indicate race, color, religion, sex or national origin):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Give name address and telephone number of three references who are not related to you and are not
previous employers.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Employment Experience
Start with your present or last job. Include military service assignments and volunteer activities.
Exclude organization names which indicate race, color, religion, sex or national origin.
Employer
Dates Employed
Work Performed
Telephone (      )
From
To
 ______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Address    
Hr. Rate/Salary
Job Title
 Starting
 Final
Supervisor    
Reason for Leaving
Employer
Dates Employed
Work Performed
Telephone (      )
From
To
 ______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Address    
Hr. Rate/Salary
Job Title
 Starting
 Final
Supervisor    
Reason for Leaving
Employer
Dates Employed
Work Performed
Telephone (      )
From
To
 ______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Address    
Hr. Rate/Salary
Job Title
 Starting
 Final
Supervisor    
Reason for Leaving
Employer
Dates Employed
Work Performed
Telephone (      )
From
To
 ______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Address    
Hr. Rate/Salary
Job Title
 Starting
 Final
Supervisor    
Reason for Leaving

Education
                                               High School College/University Graduate/Professional
School Name                                                                                                            
Years Completed: (Circle)   9    10    11    12   1    2    3    4 1    2    3    4
Diploma/Degree:      
Describe Course of Study:

     
Describe Specialized Training,
Apprenticeship, Skills, and
Extra-Curricular Activities		      

Indicate Languages you speak, read and/or write.
  
FLUENT
GOOD
FAIR
SPEAK
      
READ
      
WRITE
      

PLEASE ANSWER ALL QUESTIONS IN THIS SECTION
Marital Status: Single    Engaged    Married    Separated    Divorced    Widowed
Height: _____ Ft. _____ In.      Weight _______ Lbs.      Sex: Male      Female
Are you over 18 years of age? Yes      No
    If not, employment is subject to verification of minimum legal age.
Have you ever been bonded? Yes      No     If yes, with what employer? ________________
What was your previous address? ________________________________________________
How long at present address?   _____Years.
How long at previous address? _____Years.

Applicants Statement
I certify that the answers given herein are true and complete to the best of my knowledge.
I authorize you to obtain an investigative consumer report containing information obtained through personal interviews with my neighbors, friends and acquaintances. This report, if obtained, may include information as to my character, general reputation, personal characteristics and mode of living.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

          ______________________________________________          ____________________
            Signature of Applicant                                                                     Date

Please mail this application to: Shield Card America, P.O. Box 58, Payson UT 84651
or Fax to: (801) 465-4188