PERSONAL INFORMATION

Last Name: *

First Name: *

  Middle:

Today's Date:

Social Security #:

Street Address:

City:

  State: -- PANJAKALAR AZCACOCTDC DEFLGAHIIA IDILINKSKY LAMAMDMEMI MNMOMSMTNC NDNENVNHNJ NMNYOHOKOR PARISCSDTN TXUTVAVTWA WIWVPR   Zip:

Phone Numbers: *

Home:   Work:   Cell:

Email Address:

EMPLOYMENT INFORMATION

Position applied for:

Referred by:
If other, please specify name:

--- Select --- Classified Ad Private Employment Agency Government Employment Agency Friend Relative No Referral Other

Are you over 18 years of age?

YES NO       If NO, a work permit is required.

To the best of your
knowledge, are you legally
eligible to work permanently
in the United States?

YES NO       Should you be hired, you will be required by law to provide documents verifying your employment eligibility.

Date you are available
to start work:

Salary or Wages desired: $ per --- per hour per week per month per year

Have you ever applied for work with us before?

YES NO       If YES, enter date:

Were you ever employed
by us before?

YES NO       If YES, enter date:

YES NO

If hired by R.L. Reppert, Inc.
you will be required to work
8 (eight) hours per day
(normally 7am to 3:30 pm),
5 (five) days per week.
Can you meet this requirement?

YES NO       If NO, please explain:

Can you work overtime
if necessary?

YES NO

Can you work off-hours
if necessary?
(Start time after 5:00pm)

YES NO

Can you work out of town
if necessary?

YES NO

Are you employed at
the present time?

YES NO

Do you have any relatives now employed by this company?

YES NO       If YES, please list name(s):

Do you have a disability
which would limit or prohibit you from performing this work for which you have applied?

YES NO       If YES, please explain:

Have you been convicted of a felony within the last 7 years?

YES NO       If YES, please describe (a conviction does not necessarily disqualify an applicant for the position being applied for):

Do you have reliable transportation in order to get
to a job within a 100 mile radius
of the Lehigh Valley?

YES NO

Do you have a valid
driver's license?

YES NO

SPECIAL QUALIFICATIONS OR SKILLS

Use this space to describe any special qualifications or skills you have acquired through special training, prior employment or general experience.

EXPERIENCE

EDUCATION

High School or Vocational School

Name:

Location:

Number of years completed?

      Did you graduate? YES NO

What was your course of study?

College

Name:

Location:

Number of years completed?

      Did you graduate? YES NO

What was your major?

What is your degree?

Did you enroll in a post graduate course of education?

YES NO       If YES, what was your post graduate field of study?       If YES, what is your post graduate degree?

Trade, Business, or Correspondence School

Name:

Location:

Number of years completed?

      Did you graduate? YES NO

What was your course of training or study?

FOREIGN LANGUAGES

Indicate foreign language(s)
you are familiar with:

Language:
Speak  Read  Write 

Fluent 
Good 
Fair 

Indicate foreign language(s)
you are familiar with:

Language:
Speak  Read  Write 

Fluent 
Good 
Fair 

MEMBERSHIPS

List Businesses, Trade, Professional, Community or Activities Memberships and any offices you may have held. (exclude any organizations the name and character of which would reveal race, religion, national origin or any other protected status):

EMPLOYMENT HISTORY

Begin with most recent employer

Employer #1:

Employment Start Date:

  End Date:

Job Title:

Job Description:

Starting Salary:

$   Ending Salary: $

Supervisor's Name:

Reason for Leaving:

Employer #2:

Employment Start Date:

  End Date:

Job Title:

Job Description:

Starting Salary:

$   Ending Salary: $

Supervisor's Name:

Reason for Leaving:

Employer #3:

Employment Start Date:

  End Date:

Job Title:

Job Description:

Starting Salary:

$   Ending Salary: $

Supervisor's Name:

Reason for Leaving:

Employer #4:

Employment Start Date:

  End Date:

Job Title:

Job Description:

Starting Salary:

$   Ending Salary: $

Supervisor's Name:

Reason for Leaving:

MILITARY SERVICE

Were you a member of the
U.S. Armed Forces?

YES NO       Branch:

Years served:

  Rank at discharge:

Describe briefly your
military duties:

PERSONAL REFERENCES

List three references (excluding relatives and former employers)

Reference #1: *

Relationship to you:

Address:

Phone Number:

Reference #2:

Relationship to you:

Address:

Phone Number:

Reference #3:

Relationship to you:

Address:

Phone Number:

APPLICANT'S STATEMENT

                The information provided by me in the application for employment is true and complete
                to the best of my knowledge. Should I be employed by R. L. Reppert, Inc., any misrepresentation
                or any false statement contained herein may be considered cause for possible dismissal.

                The information provided by me in the application for employment is true and complete to the
                best of my knowledge. Should I be employed by R. L. Reppert, Inc., any misrepresentation or any
                false statement contained herein may be considered cause for possible dismissal.

                R. L. Reppert, Inc. has my permission to contact directly or employ the services of investigative
                agencies to obtain all necessary information from the references I have listed, or any other
                sources, concerning my prior employment, personal history or credit standing and I release all
                parties from any possible damages resulting from disclosing such information with or without prior
                written notice to me. I reserve the right to know the names and addresses of any investigative
                agencies used in order that I may learn the information contained in any reports furnished to
                R. L. Reppert, Inc.

                I understand this application does not constitute an employment contract of any kind.
                Should I be employed by R. L. Reppert, Inc., I may resign such employment at any time at
                my discretion with or without prior notice and R. L. Reppert, Inc. may terminate my employment
                at any time at their discretion, with or without cause and with or without prior notice.

                This application will be considered valid for a period of 7 (seven) days. After 7 (seven) days
                it may be necessary for me to submit a new application.

                I have read and understand the above statements
                and I agree with the terms stated:  AGREE