Name*
Address*
City, State Zip*
Telephone Number*
Position applying for
Are you requesting full or part time?
Hourly Wage Expected
Available to start when (mm-dd-yyyy)?
Have you ever been convicted of a felony?* YesNo
If Yes, please explain:
Do you have a valid Missouri Driver's License?*YesNo
Do you have a valid Missouri Commercial Driver's License?*YesNo
If so, what Class? (ex. A, B, C, or E)
Can you lift 100 pounds?* YesNo
Can you lift 250 pounds?* YesNo
Can you carry 100 pounds?* YesNo
Can you push/pull 250 pounds on a cart?* YesNo
Can you push/pull 500 pounds using a cart?* YesNo

Hours available to work

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Previous Work Experience

Name of Employer
Address
Phone Number
Pay Rate
Supervisor
Employment start date (mm-dd-yyyy)
Employment end date (mm-dd-yyyy)
Position / Responsibilities
Reason for leaving

Name of Employer
Address
Phone Number
Pay Rate
Supervisor
Employment start date (mm-dd-yyyy)
Employment end date (mm-dd-yyyy)
Position / Responsibilities
Reason for leaving

May we contact all the employers above as a reference? YesNo

High School Attended
Address
Did you graduate from high school?* YesNo
With a diploma or GED?*
College - Vocation - Military Experience
Course of Study
Please tell us any training, or other information you would like us to know

Email address*

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