PERSONAL DETAILS
Name/last, First, Middle
Date (mm/dd/yy)
 Telephone
Referred By:
Address/Street, City, State, Zip Code
 Have you ever been employed by KBR ?
Yes No
Shp Year
Have you friends or relatives who work here? Names
 Are you 18 years of age or older?
 Social Security
 
GOALS
Position Desired
Salary Required
 Date available to begin employment
 
EDUCATION
NAME AND LOCATION
 MAJOR SUBJECT
 DEGREE RECIEVED
HIGH SCHOOL

COLLEGE

COLLEGE

List office or shop machine operated    
 
 
 
 
PREVIOUS EMPLOYMENT (REQUIRED ON THE FORM) May include verifiable volunteer work experience in this section
1
Company Name
 Date Employed
From To 		Phone
Address/Street, City, State, Zip Code
 Immediate Supervisor’s Name and Title

 Posistion Title
May we contact?
Yes No 		Job Discription
 Reason for leaving
Starting Salary $
 Final Salary $
  
2
Company Name
 Date Employed
From To 		Phone
Address/Street, City, State, Zip Code
 Immediate Supervisor’s Name and Title

 Posistion Title
May we contact?
Yes No 		Job Discription
 Reason for leaving
Starting Salary $
 Final Salary $
  
3
Company Name
 Date Employed
From To 		Phone
Address/Street, City, State, Zip Code
 Immediate Supervisor’s Name and Title

 Posistion Title
May we contact?
Yes No 		Job Discription
 Reason for leaving
Starting Salary $
 Final Salary $
  
4
Company Name
 Date Employed
From To 		Phone
Address/Street, City, State, Zip Code
 Immediate Supervisor’s Name and Title

 Posistion Title
May we contact?
Yes No 		Job Discription
 Reason for leaving
Starting Salary $
 Final Salary $
  
     
     
Have you ever been convicted of a felony?
Yes No
A “YES” answer will not necessarily disqualify
you from employment		 Can you, after employment, present
documentation showing that you are lawfully
employable in the United States?
Yes No 		 
 
Agreement:

I understand that the U.S. Government requires companies to verify my eligibility for U.S. employment and my identity. I understand that Kitchens By Rutenschroer must decline to hire me if I fail to present adequate proof of my Eligibility and identity.

I understand that if employed, Kitchens By Rutenschroer does not guarantee that such employment will last any definite length of time. I certify that all statements herein are made truthfully and without evasion and further agree that such statements may be investigated and if found to be false may result in my dismissal.
   
SIGNATURE OF APPLICANT  
This application will remain active for six months. If you wish to be considered for employment after this period, you must reapply.
Name
 Date (mm/dd/yy)
  Social Security Number
 
Yes or No:
Please list all the qualifications in the table below
Do you have or have you ever been treated for any of the following (Answer YES or NO)
 
1 EPLIEPSY Yes No
2 DIABETES Yes No
3 CARDIAC DISEASE Yes No
4 ARTHRITIS Yes No
5 AMPUTATED FOOT, LEG, ARM, OR HAND Yes No
6 LOSS OF SIGHT OF ONE OR BOTH EYES PARTIAL LOSS OF UNCORRECTED VISION MORE THAN 75% BILATERALLY Yes No
7 RESIDUAL DIABILITY FROM POLIOMYELITIS Yes No
8 CEREBRAL PALSY Yes No
9 MULTIPLE SCLEROSIS Yes No
10 PARKINSON’S DISEASE Yes No
11 CEREBRAL VASCULAR ACCIDENT Yes No
12 TUBERCULOSIS Yes No
13 SILICOSIS Yes No
14 PSYCHO NEUROTIC DISABILITY FOLLOWING TREATMENT IN A RECOGNOZED MEDICAL OR MENTAL INSTITUTION Yes No
15 HEMPHILIA Yes No
16 CHRONIC OSTOMYELITIS Yes No
17 ALKALOSIS OF JOINTS Yes No
18 HYER INSULARISM Yes No
19 MUSCAULAR DYSTROPHIES Yes No
20 ARTERIC SCLEROSIS Yes No
21 VARICOSE VEINS Yes No
 
QUESTIONS
Please answer all questions
1 Do you have a valid driver’s license?
2 Have you ever been convicted of a felony?
3 Have you ever had a DUI before?
4 Are you currently employed at this time?
5 Can you read a tape measure 1/8th, 3/8th, 5/16th, 11/16th?
6 If you have a cell phone, please list the number.
7 Please list your home phone number.