Diversified Systems, Inc. Job Application

First Name:
 Middle Name:
 Last Name:
(Nickname)
 Social Security No.
 Email:
  
Current Address:
Street:
City: State: Zip:

Telephone:
Length of Residence:

Previous Address:
Street:
City: State:
Zip:
Are you a U.S. citizen?
Yes
No 		If not, have you the legal right to remain permanently in the U.S.?
Yes
No

Can you verify your legal right to work in the U.S. by providing a birth certificate, proof of U.S. citizenship or by some other means? (Proof of U.S. citizenship or immigration status is required upon employment.)
Yes
No

If you are under 18 can you furnish a work permit? Yes No

Position(s) applying for:
 Referred to this company by:

References

3 persons you have known for at least 1 year (not a relative or employer) If applying for a professional position, please include at least 1 recent professional associate.

Name:
 Occupation:
 How Long Known:
Address:
 City:
 State:
Name:
 Occupation:
 How Long Known:
Address:
 City:
 State:
Name:
 Occupation:
 How Long Known:
Address:
 City:
 State:
List any relatives employed by dsi:
 List any friends employed by dsi:
Kind of work wanted (1): Kind of work wanted (2):
Other kinds of work in which interested:
 Hours preferred:
Can you travel if job requires?
Yes
No 		Do you have access to a car?
Yes
No
What is the least amount of salary you expected?
$ per 		Date available to start work:
   

Remarks

Has your driver's license ever been revoked?
Yes
No 		Has your driver's license ever been suspended?
Yes
No

Have you ever been indicted, convicted of, or entered a plea of guilty to, a felony or misdemeanor other than parking or traffic violation?
Yes
No

IF YES, EXPLAIN FULLY: when, where and disposition of case.

Have you ever been convicted of a criminal offense under another name?
Yes
No

Education:

Elementary, Junior High: Location:
 Attended From:
 To:
Did you graduate?
Yes No 		     
High School: Location:
 Attended From:
 To:
Did you graduate?
Yes No 		Graduation Date:
    
Trade or technical: Location:
 Attended From:
 To:
Did you graduate?
Yes No 		Graduation Date:
 Degree:
 Major Subject:
Business, Correspondence: Location:
 Attended From:
 To:
Did you graduate?
Yes No 		Graduation Date:
 Degree:
 Major Subject:
College or University: Location:
 Attended From:
 To:
Did you graduate?
Yes No 		Graduation Date:
 Degree:
 Major Subject:
Graduate Study: Location:
 Attended From:
 To:
Did you graduate?
Yes No 		Graduation Date:
 Degree:
 Major Subject:

School Record

High School

Scholastic Standing (estimate if not known):

Scholastic Honors:

Special Accomplishments:

Expenses Earned (Percent & How Earned):

College/Graduate Study

Scholastic Standing (estimate if not known):

Scholastic Honors:

Special Accomplishments:

Expenses Earned (Percent & How Earned):

Miscellaneous Training

Languages Spoken Fluently:
 Languages Written Fluently:
 Factory or Shop Machines Operated:
Typing Speed (W.P.M.)
 Shorthand Speed (W.P.M.)
 Office Machines Operated:
Read Blue Prints Machine Drawings Rule or Scale
Micrometer Schematics Do Set Up
Layout

Activities

Organizations, clubs, professional societies, trade or other associations of which you are a member (omit any whose nature or character indicates a union or race, religious creed, color, national origin or the ancestry of its members).

Hobbies, recreations and leisure interests:
 Civic awards and offices:

Employment History

Name of Present or Last Employer:
Address:
Type of Business:
Starting Date:
 Starting Pay:
 May we contact?
Yes No
Leaving Date:
 Ending Pay:
 Reason for Leaving:
Job Title (Last):
 Name of Supervisor:
 Supervisor's Job Title:

Description of Work and Responsibility:

Name of Next Previous Employer:
Address:
Type of Business:
Starting Date:
 Starting Pay:
 May we contact?
Yes No
Leaving Date:
 Ending Pay:
 Reason for Leaving:
Job Title (Last):
 Name of Supervisor:
 Supervisor's Job Title:

Description of Work and Responsibility:

Name of Next Previous Employer:
Address:
Type of Business:
Starting Date:
 Starting Pay:
 May we contact?
Yes No
Leaving Date:
 Ending Pay:
 Reason for Leaving:
Job Title (Last):
 Name of Supervisor:
 Supervisor's Job Title:

Description of Work and Responsibility:

Name of Next Previous Employer:
Address:
Type of Business:
Starting Date:
 Starting Pay:
 May we contact?
Yes No
Leaving Date:
 Ending Pay:
 Reason for Leaving:
Job Title (Last):
 Name of Supervisor:
 Supervisor's Job Title:

Description of Work and Responsibility:

Additional Experience

State what you did in any periods not already covered, including part-time or self employment:

Dates Description

Affirmative Action

As employers/government contractors, we comply with government regulations and affirmative action responsibilities.

Solely to help us comply with government recordkeeping, reporting, and other legal requirements, please complete the Affirmative Action Survey below. These data are for periodic government reporting and will be kept in your confidential file.

We appreciate your cooperation and assistance.

Sex:
Male Female 		Date of Birth:

Race:

Check if any of the following are applicable:
Vietnam Era Veteran (8/64 - 1/73)
Disabled Veteran
Handicapped Individual

Military Service

Branch of Service:

Date Entered:
 Date Discharged:
 Months Active Duty:
Present Draft,
Reserve, or Military Status:
Discharge Rank:
Condition of Discharge:

Service School:
Honors Received:

Nature of Duties and any Special Training or Experience:

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not intended to be a contract of employment.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Diversified Systems, Inc.

Do you certify that the answers given are true and complete to the best of your knowledge?
Yes No