Date:___________________

Position(s) Desired (1) ____________________________________(2)__________________________________

Available for:    Full Time_________Part Time _________Temporary ____________

Date Available for Employment: __________________Minimum Salary Expectation ________________________

PERSONAL INFORMATION

Name: ____________________________________________________________________________________

Home Address: ____________________________City ________________State _______Zip Code___________

Telephone Number(s) where you can be reached : Home ____________________Other _____________________

SOCIAL SECURITY NUMBER:  ___ ___ ___ - ___ ___ - ___ ___ ___ ___

DATE OF BIRTH: ___ ___ / ___ ___ / ___ ___ ___ ___  PLACE OF BIRTH:______________________________

Do you have a disability, a handicap, or medical condition that limits your job performance?

Yes _____ No _____ If yes, please describe and state how it affects your ability to work:_____________________

_________________________________________________________________________________________

Drivers License number ___________________License Class ____________________________

Have you ever been convicted of a felony or misdemeanor: Yes ____ No ____ If yes, please give date(s) and explain____________________________________________________________________________________

_________________________________________________________________________________________

List any relatives working for us and relationship to you.

(1)_________________________________________(3)_________________________________

(2)_________________________________________(4)_________________________________

EDUCATION AND TRAINING

Circle Highest Grade Completed:       7 or less         8          9         10         11         12          More

Last High School Attended:  School Name___________________________City______________________State_________

High School Diploma Awarded:    Yes______ No______  If No   GED?   Yes _____ No _____

EMPLOYMENT HISTORY

In the space provided below, give your employment history, beginning with your present or most recent employer and list all positions held.

Name of Employer ___________________________From _______________________To __________________

Address __________________________________________________________________________________

Job Title _________________________________Telephone Number __________________________________

Supervisor's Name and Title ___________________________________________________________________

Reason for Leaving _________________________________________________________________________

Please Describe the Nature and Duties of Your Position: _________________________________________________________________________________________

__________________________________________________________________________________________

Name of Employer ______________________________From ____________To ________________________

Address _________________________________________________________________________________

Job Title __________________________________ Telephone Number ________________________________

Supervisor's Name and Title ___________________________________________________________________

Reason for Leaving __________________________________________________________________________

Please Describe the Nature and Duties of Your Position: ________________________________________________________________________________________

________________________________________________________________________________________

REFERENCES

ADDITIONAL INFORMATION

The following questions are not mandatory:  Answers these questions on a voluntary basis only.

Date Graduated from High School _________________________________________________________________

Are you married? ___________________________ Single? ________________Divorce? ______________________

How long have you lived in Barnwell County? _________________________________________________________

Your Signature:___________________________________________________________ Date: ________________