Northwest Technologies, Inc.

How did you hear about us? Newspaper Ad Employment Agency Current Employee Other
Are you legally eligible to work in the United States? Yes No
Are you over the age of 18 years? Yes No
Can you with or without reasonable accommodation perform the essential functions of this job? Yes No
Have you ever applied to NWT before? (If yes, please give date below.) Yes No
Date / MM / DD YYYY
Have you ever worked for NWT before? (If yes, please give date below.) Yes No
Date / MM / DD YYYY
Have you ever been convicted of a felony? (A conviction will not necessarily disqualify you.) Yes No
If yes, please explain:
Do you have a valid driver's license? Yes No
Have you been convicted of any moving violations in the past five years? Yes No
If yes, please explain:
What salary or rate of pay do you expect to receive if employed?
Have you ever been fired or asked to resign from a job? Yes No
If yes, please explain:
Are you willing to work overtime on short notice? Yes No
Days and Hours Available: (If employed, I will notify my supervisor in writing, should my availability change.) Any Days Swing 3pm to 11:30pm Graveyard 11pm to 7:30am
On what date would you be available to work? / MM / DD YYYY
IN CASE OF EMERGENCY NOTIFY:
Name First Last
Phone - (###) - ### ####

EDUCATION:
High School Location
High School Major
High School # of Years
High School Diploma/Degree
College School Location
College School Major
College School # of Years
College School Diploma/Degree
Vocational School Location
Vocational School Major
Vocational School # of Years
Vocational School Diploma/Degree
Describe any specialized training, apprenticeships, licenses or skills that will help you perform the duties of this
position: (DO NOT LEAVE BLANK) *

Work History
Company Name
From / MM / DD YYYY
To / MM / DD YYYY
Start Salary $ . Dollars Cents
End Salary $ . Dollars Cents
Name and Title of Supervisor
May we contact Yes No
Phone - (###) - ### ####
Describe your duties
Reason for leaving and explanation
Company Name
From / MM / DD YYYY
To / MM / DD YYYY
Start Salary $ . Dollars Cents
End Salary $ . Dollars Cents
Name and Title of Supervisor
May we contact Yes No
Phone - (###) - ### ####
Describe your duties
Reason for leaving and explanation
Please provide any other information that you feel will help us in considering your application for employment.
REFERENCES (Please list three persons, who are not related to you or previous supervisors, who can provide
professional references.)
Name
Address
Phone Number
Relationship/Occupation
Years Known
Name
Address
Phone Number
Relationship/Occupation
Years Known
Name
Address
Phone Number
Relationship/Occupation
Years Known
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