Delta
 Properties
   Grand Rapids & Lansing		 Today's Date is 8/28/2008 401 Hall St.
Box 95
Grand Rapids, MI 49503
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Name
     
First Middle Initial Last
 
Present Address
       
Street City State Zip
 
Phone Number
   
 
Are You 18 Years or Older?
   Yes No
 
Are you a U.S. citizen or an Alien authorized to work in the United States?
   Yes No
 
Do you speak any foreign languages fluently?
 
 
Have you ever been convicted of a felony or a misdemeanor within the last 15 years*?
   Yes No If Yes, Describe:
 
Do you have a valid Driver's License?
   Yes No If yes, Drivers License Number:
 
Employment Desired
  Position
  Date you can Start
  Salary Desired
  Any special skills that would be helpful?
  Are you employed now?  Yes No
  May we inquire of your present employer?
           
Education
    Name and Location No. of Years Attended Did you Graduate? Subjects Studied
  Grammar School
  High School
  College
  Trade or Business  School
 
US Military or Naval Service
What service did you serve in? (if any)
 
Rank
 
Present membership in National Guard or Reserves
 
 
Employment History (List below last three employers, starting with most recent first.)
Dates Employed Name and Address Salary Benefits Received Position Held Reason for Leaving
 
to
 		     Indiv. Health    
Family Health
Dental
None
 
to
 		     Indiv. Health    
Family Health
Dental
None
 
to
 		     Indiv. Health    
Family Health
Dental
None
 
References (Give the names of three persons not related to you, whom you have known at least one year.)
Name & Address Telephone # Relationship Years Acquainted
1.    BusinessPersonal  
2.    BusinessPersonal  
3.    BusinessPersonal  
 
Physical Record
  Do you have any physical limitations that preclude you from performing any work for which you are being considered?
  Yes  No
  If Yes, what can be done to accommodate your limitation?
 
 
Email Address
 
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be ground for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employments and any pertinent information they may have, personal or otherwise, and release all parties from liability for an damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice."
   
 Do you agree to the above statement?  Yes No

Today's Date:       (MM/DD/YY)

* You will not be denied employment solely because of conviction record, unless the offense is related to the job for which you have applied.
 

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