Employment Application

It is the policy of Patco Electrical Services, Inc. to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.

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Which Store will you be applying for:

Applicant Name:

Address:

City/State/Zip:

Number of years at this address:

Daytime phone:

Evening phone:

Who should be contacted if you are involved in an emergency?

Contact Name:

Relationship to you:

Address:

City/State/Zip:

Daytime phone:

Evening phone:

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Job Position Applied For:

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Salary Desired:

Referral Source: Who referred you to our company?

Have you applied to our company previously?

If yes, when?

Are you at least 18 years old?

How will you get to work?

Driver's License Number:

What state issued your license?

If you are offered employment, when would you be available to begin work?

Are you legally eligible for employment in the United States?

Are you able to perform the essential functions of the job position with or without reasonable accommodation?

What reasonable accommodation, if any, would you require?

Have you ever been convicted of any crime, including traffic violations?

If yes, please describe:

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.

Applicant Employment History: List your current or most recent employment first.

Employer Name:

Address

City/State/Zip:

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

Employer Name:

Address

City/State/Zip:

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

Employer Name:

Address

City/State/Zip:

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

Applicant's Education and Training: List your education and training.

High School Name and Address:

Last Grade?

Diploma?

College Name and Address

Did you receive a degree?

If yes, degree received:

Other Training (graduate, technical, vocational):

Awards, Honors, Special Achievements:

Applicant's Skills: List any skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

References: List any two people who would be willing to provide a reference for you.

Name:

Address:

City/State/Zip:

Telephone:

Relationship:

Name:

Address:

City/State/Zip:

Telephone:

Relationship: