Printable Job Application

Application for Employment

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

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
Bratrud Dusti Jo 1-9-18
Street Address Home Phone
( )
506 4th street -
641-430-XXXX
City, State, Zip

Kensett, IA, 50448

Business Phone Email Address:
( ) - [email protected]
(641) 324-1712
What was your previous address? How long at present
previous
address?
1325 390th street
_________
15 Years
________ 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?

_________
3 Years
________ 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?

High school councelor

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

Yes immediately
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.

http://acummingsdesign.com/envrecycle/application.htm (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?

XXXXXXXXX IA Yes No

Education

No. of
Course of Did you Degree or
School Name and location of school years
study graduate? diploma
completed
College Yes
Niacc Gen EDS 1 No
High Yes
Northwood-Kensett High School 3 1/2 No
Trade Yes
School No
Other Yes
No

Military
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 To
Rank at Discharge
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

Northwood Lutheran Retirement Home (641-324-1712) -
Address Employed (Start Month and Year)
701 9th St N, Northwood, IA 50459

From Nov.1 To Present

1.
Name of Supervisor Hourly Rate

Kris Jacobs Start 13.50 Last 16.00

Start Job Title and Describe Your Work Reason for Leaving

CNA- help residents with their daily activities presently employed

http://acummingsdesign.com/envrecycle/application.htm (2 of 4) [5/11/2003 12:35:01]

Printable Job Application

Company Name Telephone

B and L Detasseling - Pioneer (XXX-XXX-XXXX
) -
Address Employed (Start Month and Year)

Fromaugust 2014 To August 2017

2.
Name of Supervisor Hourly Rate

Bob Miller Start 7.50 Last 10.00

Start Job Title and Describe Your Work Reason for Leaving
Supervisor- watch workers and make sure that they’re doing their job Seasonal work
Company Name Telephone
Northwood Municipal Swimming Pool (XXX-XXX-XXXX
) -
Address Employed (Start Month and Year)

627 Central Ave. From June 2017 To August 2017

3.
Name of Supervisor Hourly Rate

Kate Hartman Start $7.50 Last $7.50

Start Job Title and Describe Your Work Reason for Leaving
Lifegaurd-Watch the swimmers and make sure that kids are safe.
Seasonal Work
Company Name Telephone
( ) -
Address Employed (Start Month and Year)

From To
4.
Name of Supervisor Hourly Rate

Start Last
Start Job Title and Describe Your Work Reason for Leaving

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.
Years
Name Address Business
Acquainted
1.
Kate Hartman
200 5th Ave N Substitute Teacer 8
2. Nicole
Venechuk 485 Thrush Ave. Librarian 2
3.
Tiffany Tiedamann 404 11th street N Daycare Provider 12

http://acummingsdesign.com/envrecycle/application.htm (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.

___________________
1/12/18 _________________________________
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

http://www.envrecycle.com/

http://acummingsdesign.com/envrecycle/application.htm (4 of 4) [5/11/2003 12:35:01]