Application For Employment
First Name:
 Middle:

 Last:
Address:
City:
State: Zip Code:
Phone:
eg. 316.555.5555
Type of work desired:
Do you have any relatives employed in this company?
(name)
Whom do you know personally in this company?
(name)
Do you have any disability, physical or other, which would prevent you from
satisfactority performing the essential functions of the job for which you
have applied?
Yes No
Are you willing to undergo a complete examination by physician?
Yes No
School Record
Name of High School and Location:
Course:
 Degrees Given:
 Hr Comp:
 Yr Att:
Name of College or University and Location (1):
Course:
 Degrees Given:
 Hr Comp:
 Yr Att:
Name of College or University and Location (2):
Course:
 Degrees Given:
 Hr Comp:
 Yr Att:
Name of Vocational or Business and Location
Course:
 Degrees Given:
 Hr Comp:
 Yr Att:
Special Training
RN LPN CMA CNA CPR
Valid Kansas Driver License Type: Other:
Do you type? Yes No Speed wpm
Operate business machines, including computers? Yes No
If so list type and software:
List any other special training or experience you have received:
Previous Employment (Beginning with present or last employment)
Name and Address of Empoyer:
Date Start:
Date End:
Rate Pay:
 Immediate Supervisor
Nature of Your Work:
Name and Address of Empoyer:
Date Start:
Date End:
Rate Pay:
 Immediate Supervisor
Nature of Your Work:
Name and Address of Empoyer:
Date Start:
Date End:
Rate Pay:
 Immediate Supervisor
Nature of Your Work:
Name and Address of Empoyer:
Date Start:
Date End:
Rate Pay:
 Immediate Supervisor
Nature of Your Work:
Name and Address of Empoyer:
Date Start:
Date End:
Rate Pay:
 Immediate Supervisor
Nature of Your Work:
References
(List at least three references who are not relatives or previous employees.)
Name:
 Occupation:
 Phone No:
Address:
Name:
 Occupation:
 Phone No:
Address:
Name:
 Occupation:
 Phone No:
Address:
U.S. Military Record
Have you served in the Armed Forces? No
Service school attended:
Date Start:
Date End:
Rank or Rate:
 Service Branch:
Military specialty:

I understand and agree that:

Any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of, or if employed, termination from employment.

It is my understanding that ParkWest Plaza (PWP) may make a thorough investigation of my entire work and personal history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by PWP. Additionally, I release from liability any person giving or receiving any such information. I understand that falsification of data so given or other derogatory information discovered as a result of this investigation may prevent my being hired, or if hired, may subject me to immediate dismissal.

I agree that my employment, if hired, shall be considered Employment at Will. I understand Employment at Will to mean that I can be terminated or dismissed at any time, with or without cause, I understand and agree that I may be required to take a physical examination by company physician, at company expense, at any time to determine if I am physically fit for the job I am to perform, and I authorize any physician or hospital to release any information which may be necessary to determine by ability to perform the duties and essential functions of a job I am being considered for prior to employment or in the future during my employment with PWP.

Although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory: overtime; shift work; a rotation work schedule; or a work schedule other than Monday through Friday.

I understand and accept these as conditions of my continuing employment. I further understand this is an application for employment and no employment contract is being offered. I have read and understand the above.