EMPLOYMENT

    SOUTHWEST FIREPLACE
    EMPLOYMENT APPLICATION

    9475 West Laraway Road, Frankfort, IL 60423 - 815-806-9700

    It is the policy of Southwest Fireplace 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.

    • Position you are applying for:

    • Your Full Name:

    • Street Address:

    • City:

    • State:

    • Zip:

    • Number of years at this address:

    • Daytime Phone:

    • Evening Phone:

    • Salary Desired:

    • per:

    • Email

    • Have you applied to our company previously?

      YesNo

    • If yes, when?:

    • Are you at least 18 years old?

      YesNo

    • Are you legally eligible for employment in the
      United States?

      YesNo

    • Are you willing to work any shift, including nights and weekends?

      YesNo

    • If no, please state any limitations:

    • Referral Source: How were you reffered to
      our company?

    • How will you get to work?

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

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

      YesNo

    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):

    EDUCATION

    List your current or most recent employment first:

    • High School Name and Address:

    • Last Grade?

      9101112

    • Diploma?

      YesNo

    • College Name and Address:

    • Did you receive a degree?

      YesNo

    • If yes, degree received:

    • Other Training (graduate, technical, vocational):

    • Awards, Honors, Special Achievements:

    SKILLS

    Applicant’s Skills: Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and select the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)
    Ability or Skill Years of Experience Rating

    Computer

    AP/AR

    Forklift

    Filing

    Sales

    Other

    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:

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

    • Contact Name:

    • Relationship to you:

    • Address:

    • City:

    • State:

    • Zip:

    • Daytime Phone:

    • Evening Phone:

    • Driver’s License Number:

    • What state issued your license?

    • Please provide any other information that you believe should be considered:

    CERTIFICATION

    I certify that the information provided on this Application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my Application, or if employment commences, immediate termination. I authorize Southwest Fireplace to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its President, the employment relationship will be entirely voluntary in nature. In other words, with appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer would have the same right. Moreover, no agent, representative, or employee of Southwest Fireplace, except in a specific written contract of employment signed on behalf of the organization by its President, has the power to alter or vary the voluntary nature of the employment relationship.

    I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND
    I UNDERSTAND AND AGREE TO ITS TERMS.

    • Signature (Print Name)

    • Date