Phone: (913) 381-6666 Fax: (913) 381-5600
7843 Riley, Overland Park, Kansas-66204
(One Block West of Metcalf)

Employment Application

Applicant Information
Last Name First Name
M.I. Date
Street Address Apartment/Unit#
City State
Zip Phone
Email Address Date Available
Social Security No. Desired Wages (per hr)
Position Applied For Date of Birth
Are you a citizen of United States? YES    NO Have you been convicted of a DUI/DWI? YES    NO
Have you ever been fired from a job YES    NO If so, when?
Have you ever been convicted of a felony YES    NO If yes, explain
High School Address
From Date To Date
Did you graduate? YES    NO Degree
College Address
Please list three professional references.
Full Name Relationship
Company Phone
Previous Employment
Company Phone
Address Supervisor
Job Title Responsibilities
Starting Salary ($) Ending Salary ($)
From To
Reason for Leaving May we contact your previous supervisor for a reference? YES    NO
Millitary Service
Branch Rank at Discharge
From Date To Date
Type of Discharge If other than honorable, explain
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
You will be on probation for the 1st 90 days.