Application for Employment
Please Print
Position(s) applied for								Date of Application
Name
	(Last)						(First)				(Middle)
Address
		(Street)					(City)			(State)	(Zip Code)
Telephone				Social Security Number
Are you over 18 years old?			Yes			No
Date available to work:
Are you willing to travel?					Will you submit to a drug test?
Have you ever been in a Drug Testing Program with a previous employer?
If yes, please list the employer and contact phone number:
EMPLOYMENT HISTORY
List your last 3 employers, starting with the most recent, including military service.
May we contact your former employers?				Yes					No
	If not, which ones:

From:	To:			Employer:
Job Title		Street Address
Immediate Supervisor:			City, State, Zip
Reason for Leaving:					Telephone No.
Hourly Rate/Salary: Start:						Final:

From:	To:			Employer:
Job Title		Street Address
Immediate Supervisor:			City, State, Zip
Reason for Leaving:					Telephone No.
Hourly Rate/Salary: Start:						Final:

From:	To:			Employer:
Job Title		Street Address
Immediate Supervisor:			City, State, Zip
Reason for Leaving:					Telephone No.
Hourly Rate/Salary: Start:						Final:

SKILLS & QUALIFICATIONS:
Summarize any training licenses, and experience that may qualify you to perform job related functions for this position:
Do you have any limitations that would affect your ability to perform the job you are applying for?
EDUCATION
High School:	City/State:
Other:	City. State:
REFERENCES
1.) Name:	Telephone:
2.) Name:	Telephone:
DRIVING RECORD :

Accident Record for the past 3 years or more:
	Date	Nature of Accident	Fatalities	Injuries
		(Head-on, rear-end, upset, etc.)
Last Accident:
Next Previous:
Next Previous:

Traffic convictions & forfeitures for the past 3 years (other than parking violations).
Location	Date	Charge	Penalty

	State		License No.		Endorsements /Type	Expiration Date
Drivers Licenses:
Current Medical Card :		Yes		No

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

B. Has any license, permit ever been suspended or revoked?

IF THE ANSWER IS YES TO EITHER A or B, ATTACH STATEMENT GIVING DETAILS

DRIVING EXPERIENCE:
Class of Equipment	Type of Equipment		DATES
		From		To
Straight Truck
Tractor & Semi Trailer (Type)
Other

TO BE READ AND SIGNED BY ALL APPLICANTS

This certifies that this application was completed by me, and that all entries are true and complete. I authorize Sporer Land to make inquires of my personal, employment, driving record, financial or medical history and other related matters when making an employment decision. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. I understand that if employed, false statements on this application will be considered sufficient cause for dismissal. I also understand that prior to being employed, I would be required to submit to a Drug Screen.

DATE:

Signature of Applicant:

Return signed applications to Sporer Land Development, Inc, PO Box 246, Oakley, KS 67748

Phone: 785/672-4319 Fax: 785/672-3409 e-mail: sporer@ruraltel.net