Name

Phone Number

Email Address

Cell Number

Mailing Address

City

State/Zip Code

How did you hear about AMPM? How did you hear about AMPM?ClientCommercialEmployeeFacebookFriendIndeedInternetJob FairNewspaper AdRelativeSchoolWebsiteOther

If under 18, can you provide a work permit? If under 18, can you provide a work permit? Yes No

Are you a Citizen of the United States? Are you a Citizen of the United States? Yes No

Are you authorized to work in the U.S.? Are you authorized to work in the U.S.? Yes No

Have you ever worked/applied for AMPM? Have you ever worked/applied for AMPM? Yes No

When?

Have you ever been convicted of a felony? Have you ever been convicted of a felony? Yes No

Explain.

Emergency Contact 1 Name

Emergency Contact 1 Phone Number

Emergency Contact 1 Relationship to You

Emergency Contact 1 Address

Emergency Contact 1 State/Zip

Emergency Contact 2 Name

Emergency Contact 2 Phone Number

Emergency Contact 2 Relationship to You

Emergency Contact 2 Address

Emergency Contact 2 State/Zip

Education - High School

Did you graduate High School? Did you graduate High School? Yes No

Education - College or University

Did you graduate College? Did you graduate College? Yes No

Degree

Education - Other School/Training

Did you graduate or complete a degree or certificate? Did you graduate or complete a degree or certificate? Yes No

Degree/Certificate

Previous Employer 1 - Company Name

Previous Employer 1 - Phone Number

Previous Employer 1 - Address

Previous Employer 1 - Supervisor

Previous Employer 1 - Job Title

Previous Employer 1 - Salary

Previous Employer 1 - Dates worked

Previous Employer 1 - Reason for leaving

Previous Employer 1 - Duties

Previous Employer 1 - May we contact your supervisor for a reference? Previous Employer 1 - May we contact your supervisor for a reference? Yes No

Previous Employer 2 - Company Name

Previous Employer 2 - Phone Number

Previous Employer 2 - Address

Previous Employer 2 - Supervisor

Previous Employer 2 - Job Title

Previous Employer 2 - Salary

Previous Employer 2 - Dates Worked

Previous Employer 2 - Reason for leaving

Previous Employer 2 - Duties

Previous Employer 2 - May we contact your supervisor for a reference? Previous Employer 2 - May we contact your supervisor for a reference? Yes No

Reference 1 - Name

Reference 1 - Phone Number

Reference 1 - Company Name

Reference 2 - Name

Reference 2 - Phone Number

Reference 2 - Company Name

Preferred Days to Work (Check all that apply) Preferred Days to Work (Check all that apply) Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Preferred Parishes to Work In (Check all that apply) Preferred Parishes to Work In (Check all that apply) Jefferson Lafourche Orleans St. Charles St. James St. John St. Tammany Tangipahoa Terrebonne Other

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Technical Skills/Experience (Check all that apply) Technical Skills/Experience (Check all that apply) Air Conditioning Tech Carpenter Electrician Heavy Equipment Hydro Blaster Instrumentation Maintenance Mechanic Painter Security Guard Welder

Helper Skills/Experience (Check all that apply) Helper Skills/Experience (Check all that apply) Electrical Helper Electronics Helper Maintenance Helper Mechanic Helper Pipe Fitter Helper Plumber Helper

Industrial Skills/Experience (Check all that apply) Industrial Skills/Experience (Check all that apply) Galata Intern Material Helper OSHA Card Process Technician Safety Technician TWIC Card

Software Programs Skills/Experience (Check all that apply) Software Programs Skills/Experience (Check all that apply) Access AutoCAD Excel Peachtree PowerPoint QuickBooks Quicken SAP Web/Graphic Design Word

Warehouse Skills/Experience (Check all that apply) Warehouse Skills/Experience (Check all that apply) Current Driver's License CDL Dispatcher Driver Expeditor Forklift Operator Certified Forklift Operator Non-Certified Shipping/Receiving Warehouse

Non-Technical Skills/Experience Non-Technical Skills/Experience Bilingual Cafe Assistant Custodian Health Care Aid Laborer Lawn Maintenance Teacher Aide (Para professional)

General Office Skill/Experience (Check all that apply) General Office Skill/Experience (Check all that apply) Administrative Assistant Cashier Customer Service Representative Date Entry General Clerical Insurance Mailroom Receptionist Receptionist/Switchboard

Bookkeeping/Accounting Skills/Experience Bookkeeping/Accounting Skills/Experience Accounts Payable Accounts Receivable Banking/Credit Union Collections Full Charge Payroll General Ledger/Bookkeeper Payroll Check Teller Ten Key Timekeeper

Professional Skills/Experience (Check all that apply) Professional Skills/Experience (Check all that apply) Accountant/Financial Analyst Chemist Drafter Engineer Help Desk/IT Lab Technician - Industrial Legal Secretary/Paralegal Purchaser/Buyer

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