933 Fillmore
Fredonia, Kansas 66736
620-378-2046
Date: 4/20/2024

Application for Employment
  Federal and state law prohibits discrimination in employment practices on account of race, color, religion, creed, national origin, ancestry, age, marital status, veteran status, non-job related disability or any other protected group status.

Name:
Last First Middle
Address:
Street City State                      Zip
Telephone:
Cell Home Work

Do you have a legal right to be employed in the U.S.?   
Are you over the age of 18?   
Have you been convicted of a crime?   
If Yes, Please provide dates and details:
How did you hear about us?
Job Interest
Position Desired:
       (If part time, hours wanted)
Wages or Salary Desired: $     Per:
Other positions for which you are qualified:
Date you are available to begin working:
Were you previously employed by our company?:   
If yes, when: Where:
Rate of pay: Position:
Reason for leaving:
Education
  Fill in the information starting with the most recent school attended.
Name of School, City, and StateDid you
graduate?		MajorDegreeGPA

Employment History
  Fill in the information starting with the most recent employer.
Company Name: Position(s) Held:
Address, City, State, Zip:
 Start Date of Employment:
End Date of Employment:
Phone: Duties & Responsibilities:
Name of Supervisor:
Base Gross Income
Starting Wage:
Ending/Current Wage:
Bonuses or Incentives: 		Reason for Leaving:
May we contact this employer for a reference?   

 
Company Name: Position(s) Held:
Address, City, State, Zip:
 Start Date of Employment:
End Date of Employment:
Phone: Duties & Responsibilities:
Name of Supervisor:
Base Gross Income
Starting Wage:
Ending/Current Wage:
Bonuses or Incentives: 		Reason for Leaving:
May we contact this employer for a reference?   

 
Company Name: Position(s) Held:
Address, City, State, Zip:
 Start Date of Employment:
End Date of Employment:
Phone: Duties & Responsibilities:
Name of Supervisor:
Base Gross Income
Starting Wage:
Ending/Current Wage:
Bonuses or Incentives: 		Reason for Leaving:
May we contact this employer for a reference?   

 
Account for all unemployment other than those due to personal injury, illness or disability.

Skills
  Please list any skills that may be related to the job for which you are applying.
Computer Skills:
Word Processing:
Software Packages:
Program Languages:
Other:

References
  Please lists three work references. If not applicable, list three personal references other than a relative.
NameRelationship to YouAddressPhone Number

Other Job Related Information
  Are there any organizations that you belong to that are job related? (Do not list any organizations that would reveal race, gender, color, religion, creed, national origin, ancestry, age, marital status, veteran status, non-job related disability or any other protected group status.)


  List any awards, publications or special accomplishments. (Do not list any organizations that would reveal race, gender, color, religion, creed, national origin, ancestry, age, marital status, veteran status, non-job related disability or any other protected group status.)

Applicant Must Read and Sign
I hereby affirm that the information provided on this application is true and complete. I also understand that any omission or misrepresentation of information provided may result in my rejection or termination from employment.
 
I authorize TCI to contact and obtain information from all references listed and release any employers or persons listed from liability for any damages from furnishing such information.
 
In the event of my employment with TCI, I will comply with all of the rules and policies of the employer. I understand that if I am employed, my employment will be at-will for no set period of time, and that my employment may be terminated for any reason at any time by either me of the company.
 
If the statement above is true, type your name in the box.
 
Applicant Signature:    Date: