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Name________________________________________________________Date of application_______________________________ LAST FIRST MIDDLE Address___________________________________City _____________________State _______Zip__________________________ Telephone____________________________________Social Security Number ___________________________________________ How were you Mmed A a 1. GENERAL INFORMATION: Are you able to perform the essential job functions of the position for which you are applying with or without reasonable accommodation? q Yes q No Have you been convicted of any felonies other than minor traffic violations during the past seven years? (A criminal record or a conviction will not automatically bar employment, but will be considered only as it reasonably relates to your fitness to perform in the position for which you are applying.) q No q Yes If yes, explain__________________________________________________ 2. EDUCATION & TRAINING: Circle last grade completed - Grade 1 2 3 4 5 6 7 8 9 10 11 12 College 1 2 3 4 Masters _____Doctorate ____ Name & Address of School Major Graduated Average Course studied or degree (Yor N) Grade Last High School Attended/Address: College or University/Address College or University/Address Other School (Technical, Vocational, Graduate, etc.) /Address List any scholarships, academic honors, awards or special achievements: 3. SKILLS Please list any skills you have that are appropriate for the position you are applying for:__________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ If required, will you work? Rotating shifts q YES q NO Saturdays q YES q NO Holidays q YES q NO Overtime q YES q NO Sundays q YES q NO Out of Town q YES q NO Are you at least 18 years of age? q YES q NO Position applying for, be specific: Salary Requirements q per hour $ q per month State fully why you believe you are qualified for this position _______________________________________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ INTERESTS / ACCOMPLISHMENTS: You may wish to list significant experience, interests & accomplishments gained while working as a volunteer or as a hobbyist that may be useful in the position(s) you are seeking. Names or organizations designating religion, race, etc. need not be mentioned. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Date you can start EMPLOYMENT HISTORY Starting with your PRESENT or MOST RECENT EMPLOYER list in consecutive order ALL EMPLOYMENT for at least the past FOUR employers. If currently employed, may we contact your employer? q Yes q No PRESENT OR MOST RECENT EMPLOYER FULL NAME OF COMPANY (AREA CODE) TELEPHONE STREET ADDRESS CITY STATE ZIP NAME & TITLE OF SUPERVISOR TITLE OF YOUR POSITION LIST JOBS HELD, DUTIES PERFORMED, SKILLS USED, & PROMOTIONS WHILE EMPLOYED AT THIS COMPANY: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ SALARY BEGIN END EMPLOYED FROM TO M/YR M/YR REASON FOR LEAVING: FULL NAME OF COMPANY (AREA CODE) TELEPHONE STREET ADDRESS CITY STATE ZIP NAME & TITLE OF SUPERVISOR TITLE OF YOUR POSITION LIST JOBS HELD, DUTIES PERFORMED, SKILLS USED, & PROMOTIONS WHILE EMPLOYED AT THIS COMPANY: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ SALARY BEGIN END EMPLOYED FROM TO M/YR M/YR REASON FOR LEAVING: FULL NAME OF COMPANY (AREA CODE) TELEPHONE STREET ADDRESS CITY STATE ZIP NAME & TITLE OF SUPERVISOR TITLE OF YOUR POSITION LIST JOBS HELD, DUTIES PERFORMED, SKILLS USED, & PROMOTIONS WHILE EMPLOYED AT THIS COMPANY: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ SALARY BEGIN END EMPLOYED FROM TO M/YR M/YR REASON FOR LEAVING: FULL NAME OF COMPANY (AREA CODE) TELEPHONE STREET ADDRESS CITY STATE ZIP NAME & TITLE OF SUPERVISOR TITLE OF YOUR POSITION LIST JOBS HELD, DUTIES PERFORMED, SKILLS USED, & PROMOTIONS WHILE EMPLOYED AT THIS COMPANY: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ SALARY BEGIN END EMPLOYED FROM TO M/YR M/YR REASON FOR LEAVING: READ CAREFULLY: I certify that the information contained in this application is correct to the best of my knowledge and understand that any misstatement or omission of information may result in denial of employment or discharge. I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. Signature ______________________________________________________________________________________________ Date____________________ 84423 US Hwy. 87 Lewistown, MT 59457 (406) 538-3465 u1L1LG ""$$h ,9"D "0(1L||____________________________________________________________ ___________________________________________________________________________________________________________________ SALARY BEGIN END EMPLOYED FROTldP.0@p      L N FHlt2n'(d Pq @k   P  B PL 0Zt2n'(d Pq @k   , B PL 0Zt2n'(d Pq @k   , .@ PL @SOln0>FH8:**X^` "LN ( !"p"r"$$$$b%d%f%& &' '''((( ))6)T)V)X)))))+b,d,f,,,,--v.x.`/4"H`/b/J0L0Z0z00000000L1N12333>4@4B4445566777778082848\8^888h:>;@;B;;;;h<j<R=T=<>>>&?(?6?X?j???????CCCDD"E@EBE 4"  Rlfv<H>@p..h($". "|$"B ")$6. "D[$"B "|$6N "" $6>" B "$6@Bnp Z \ ^ j l  J~~. "|$". "!$". "|$"B "|$6B "PS$6D "PS$60 "PS$"     J L N HNpHppppH "|">$6. "|$"D "PS$6($"B "|$6N "|" $6>" NL^ln>T*RRRRRRRR. "PS$"D "PS$6D "D[$6B "|$6. "|$"> $6V(((N "|" $6>" B "|$6. "PS$": "|" $">" . 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