Clark Jeary | Lincoln, NE

Name of Employer, City, State, Phone No

Salary

Position

Supervisor's Name

Reason for Leaving

8401 South 33rd • Lincoln, NE 68516 • (402) 489-0331 •(402) 489-0462 Fax

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Online Employment Application

First Name:

Middle Name:

Last Name:

Address (No. & Street):

Apt. #:

City:

State:

Zip:

Phone Number:

Cell Phone Number:

Social Security Number:

Type of work desired:

1st Choice:

1st Choice Shift:

2nd Choice:

2nd Choice Shift:

Full Time/Part Time

	Full Time		Part Time
	On Call		Weekend

I can furnish the proper documents to prove my right to work in the U.S.(i.e. picture ID and Social Security Card, Birth Certificate, U.S. passport, Certificate of U.S. Citizenship or Naturalization; unexpired foreign passport or resident alien card, both with employment authorization, etc.):

Yes No

Are you at least 16 years of age?

Yes No

Do you have any relatives working at Clark Jeary?

Yes No

Have you ever been employed by Clark Jeary?

Yes No

If yes, list dates and position:

Who referred you to us for employment?

Friend
Employee
Newspaper
Internet Other

Are you currently employed?

Yes No

May we contact your present employer?

Yes No

If your former employment references, education or military service are under a name other than indicated, please list below:

First Name:

Last Name:


Name of High School:
Location of High School:
Attended From/To:
Did You Graduate?

College, Trade, Business or Correspondence:
Location:
Attended From/To:
Did you Graduate?
Title/Degree:
Major/Subject:

Type	Organization or State Issued	Date Issue	Number

Professional Licenses and/or Certifications:

REFERENCES: Name three persons not related to you, whom you have known at least one year
Name	Address	Home Phone No.	Work Phone No.	Years Acquainted

PLEASE READ:

I certify that all the information submitted by me on this application is true and complete and I understand that if any false information, omissions, or misrepresentation are discovered, my application may be rejected. In addition, if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to the company’s rules and regulations. I also agree that my employment and compensation can be terminated with or without cause and with or without notice at any time, at either mine or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than it’s administrator, and then only when in writing and signed by the administrator, has any authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.