Times-Citizen Communications 406 Stevens Street Iowa Falls, IA 50126 Phone: 641-648-2521 Email: firstname.lastname@example.org Subject NAME AND ADDRESS First Name (required) Middle Initial Last Name (required) Address City State ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Telephone (required) Email Address (required) If under 18, please list age JOB TYPE Position Applying For ... I am seeking a: Full-Time Only Part-Time Only Full or Part-Time Weekends ADDITIONAL INFORMATION Have you been employed by this organization in the past? Yes No I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States. Yes No Have you ever been convicted of, or entered a plea of guilty, no contest, or had a withheld judgement to a felony? Yes No Do you have a Driver's License? Yes No Type of license Operator Commercial (CDL) Chauffeur State of Issue? EDUCATION Name of High School Number of High School Years Completed Name of College or Business/Trade School Number of College Years Completed College Major College Degree Work Experience Please list previous employers Name of Employer Address City State Zip Phone Employment Dates (From - To) Your Last Job Title Reason for leaving May we contact this employer? Yes No Name of Employer Address City State Zip Phone Employment Dates (From - To) Your Last Job Title Reason for leaving May we contact this employer? Yes No Name of Employer Address City State Zip Phone Employment Dates (From - To) Your Last Job Title Reason for leaving May we contact this employer? Yes No REFERENCES Please list two references other than relatives or previous employers. Name Phone Name Phone Attach Resume: I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated. Digital Signature Date Times-Citizen Communications is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications. Thank you for completing this application form and for your interest in our business.