Employment Application

                                                Date: 

                                     Last Name:

                                     First Name:

                           Current Address - Number and Street: 

                               City, State, ZIP:

                    Home Phone Number:

                                E-mail address: 

                                   If hired, can you provide verification of your legal right to work in the United

States? (Documentation demonstrating legal right to work in the United States will be required upon hiring)

                        Position Applied For:

                      Salary Requirements:

                                                                   Were you referred to us? - (please give referrals name)  

                                    Have you applied to us within the last six months? If yes, please give date.  

                                List any activities, affiliations, etc. you feel would be relevant in the evaluation  

                    of your qualifications for the position you seek. (e.g. professional societies, academic

                    achievements, patents, positions in outside organizations.)

                      Name and Address of Last High School: 

                                 Degree Earned:

                                                                      Name and Address of Technical or Vocational School: 

                                                                  Name and Address of Jr. College, College, or University: 

Academic Major and Degree Earned:

                 Other details of experience or training. Include information on adult education programs: 

State your most recent employer:

                                 Company Name:

                                Type of Business:

                       Starting & Ending Date:

                     Starting & Ending Salary:

           Starting & Ending Position Title:

           Name of Immediate Supervisor:

                    Supervisor's Position Title:

                                                  Phone:

                                                 Explain reason for leaving:  

                                                                                Please describe your duties and responsiblilities:  

                                                                                     Can we contact your present employer now?  

                                   Have you ever been convicted of a felony crime which has not been annulled  

               or expunged or sealed by a court? If yes, give dates, places, courts, charges, and dispostion

List three individuals not previously shown who have been in a position to objectively evaluate your training, experience and capabilities:

                                                    Name:

                                           Occupation:

                                                   Phone:

                                                    Name:

                                            Occupation:

                                                    Phone:

                                                     Name: 

                                           Occupation:

                                                   Phone:

                              Provide any additional information necessary to describe your full qualifications:

When you press the Submit button, it will e-mail your answers to me, or you can mail your answers to the following address: Varney Clean Care, P.O. Box 167, Worland, WY 82401. Be sure to include your name and phone number so I will be able to get in touch with you. Once I receive your information and know that you are interested in being a part of our team, I will contact you in order to schedule a time to meet with you in person.