APPLICATION FOR

EMPLOYMENT
An Equal Opportunity Employer
Position applying for:

Location:

Name:

Date:

Present Address:
Street:
Home Phone:

City:
Cell Phone:

State:

ZIP:

State:

ZIP:

Email:

Permanent Address (if different than Present Address):

Street:

City:

How were you referred to Peterson?

Do you have any relatives or friends working for any of the Peterson companies?

Yes

No

If yes, state name(s) and relationship to you:

Name:

Relationship:

Name:

Relationship:

Have you ever applied to or worked for any of the above Peterson companies?

Yes

No

Overtime is normal part of our business. Are you available to work overtime?

Yes

No

Are you available to work evenings and/or weekends?

Yes

No

If yes, when:
Your availability:

Where:
Full-time

Part-time

If hired, on what date can you start work?

Salary desired?

Do you have a valid drivers license?

Yes

No State:

Do you have a commercial drivers license?

Yes

No State:

Do you have HAZMAT certification?

Yes

No

Do you have other endorsements?

Yes

No Specify:

If yes, drivers license number:

per

State:

Are you at least 18 years old?

Yes

No

If hired, can you present evidence of your legal right to live and work in this country?

Yes

No

Are you able to perform the essential functions of the job for which you are applying, either with or
without reasonable accommodation?

Yes

No

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/
employees to perform essential functions. Hire may be subject to passing a medical examination, and skill and agility tests.)
HAVE YOU EVER BEEN CONVICTED OF A CRIME? (Do not include (a) traffic tickets; (b) convictions of marijuana-related offenses more than
two years old; (c) convictions that have been judicially ordered, sealed, expunged or statutorily eradicated; or (d) misdemeanor convictions
that have been judicially dismissed.)
No
Yes
IF YOU ANSWERED YES, please explain and include the dates, courts, nature of offense and/or dispositions (do not provide any information
concerning a referral to, participation in, any pretrial or post-trial diversion program):

NOTE: An affirmative answer to the preceding question will not necessarily disqualify you for employment.

Employment History
List below all present and past employment starting with your most recent employer through at least the last seven
years). You may attach a separate sheet if necessary. You must complete this section even if attaching a resume.
Please list and explain any gaps in employment at the end of this section.
Yes

Have you ever been discharged or asked to resign by an employer?

Name of Employer:

Type of Business/Industry:

Address:
Dates of Employment:

No

Phone Number:
From:

Job Title:

(Month & Year)

To:

(Month & Year)

Immediate Supervisors Name:

Pay Rate:

per

Reason for Leaving:

Job Duties:

May we contact this employer for a reference?

Yes

Name of Employer:

Type of Business/Industry:

Address:
Dates of Employment:

No

Phone Number:
From:

Job Title:

(Month & Year)

To:

(Month & Year)

Immediate Supervisors Name:

Pay Rate:

per

Reason for Leaving:

Job Duties:

May we contact this employer for a reference?

Yes

Name of Employer:

Type of Business/Industry:

Address:
Dates of Employment:

No

Phone Number:
From:

Job Title:

(Month & Year)

To:

(Month & Year)

Immediate Supervisors Name:

Pay Rate:

per

Reason for Leaving:

Job Duties:

May we contact this employer for a reference?

Yes

Name of Employer:

Type of Business/Industry:

Address:
Dates of Employment:
Job Title:

No

Phone Number:
From:

(Month & Year)

To:

(Month & Year)

Immediate Supervisors Name:

Pay Rate:

per

Reason for Leaving:

Job Duties:

May we contact this employer for a reference?

Please list dates and provide explanation for any gaps of employment that exceed two months:

Yes

No

Education, Training, Skills, Certifications

School

Name and Address

Years
Completed

Did you
graduate?

Degree or Diploma

High
School

College

College

Vocational/
Trade

Have you obtained any special skills or abilities as the result of service in the military?

If so, please describe:

Please list any other specific experience, training, qualifications, or skills you feel make you especially suited for work at Peterson?

Please specify and rank your computer software skills as follows:

Program(s) Used

Level of Expertise

Word Processing Software

Beginning

Intermediate

Expert

Spreadsheet Software

Beginning

Intermediate

Expert

Email

Beginning

Intermediate

Expert

Database Applications

Beginning

Intermediate

Expert

Order Entry/Management

Beginning

Intermediate

Expert

References
List three people who are not related to you who can comment on your work habits, preferably current/former supevisors:
Name

Position

Phone

Years
Known

Relationship

Acknowledgement and Agreement

Please read carefully, initial each paragraph below, and sign below:

Initials

Initials

Initials

Initials

Initials

Date

I certify that the facts set forth above are true and complete. I further certify that I have not
knowingly withheld any information that might adversely affect my chances for employment.
I further certify that I, the undersigned applicant, have personally completed this application.
I understand that any omission or misstatement of material fact on this application or on any
document used to secure employment shall be grounds for rejection of this application or
for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize Peterson to thoroughly investigate my references, work record, education
and other matters related to my suitability for employment and, further, authorize the
references I have listed to disclose to the company any and all letters, reports and other
information related to my work records, without giving me prior notice of such disclosure.
In consideration of my employment, if I am hired, I agree that my employment and
compensation can be terminated at will, with or without cause, at any time, either at my
option or at the option of Peterson and that no promises or representations contrary to the
foregoing are binding on Peterson unless made in writing and signed by me and Petersons
designated representative.
I understand that , in order to be hired, I may be required to sign authorization forms(s)
permitting Peterson to obtain consumer reports, consumer credit reports, and/or
investigative consumer reports. If so, I will be provided with the authorization form(s). I
understand that signing the Employment Application does not obligate me to sign such
forms(s), although I understand that Peterson may not further consider me for employment
if I choose not to sign such form(s), if requested.
I understand that offers of employment must be approved by the Director of Human
Resources and will be contingent upon successful completion of a pre-employment drug
screen, background and reference check and proof of satisfactory driving record and
employment physical, where applicable.

Applicants Signature