Employment Application

Background Information

Position(s) Applied For

Are you looking for

Full time

Part-time

Temporary

Date available to work

Are you on layoff or subject to recall?

Yes

No

Do you have a current DOT health card?

Yes

No

Have you applied before?

Yes

No

Have you been employed here before?

Yes

No

How did you learn about us?

Friend

Relative

Walk-in

Employment Agency

Other

Were you referred to us by a current Phillips employee?

Yes

No

Person & phone # to contact in case of emergency

Personal Information

First Name

Middle Initial

Last Name

Address

City

State

Zip

Phone Number

Social Security #

Drivers' License Information

Drivers' License #

State

Expiration Date

Class

Number of points on your license

Do you have a license in another state?

Yes

No

Do you have a COMMERCIAL DRIVER’S LICENSE?

Yes

No

References

Give name, address, and phone number of two (2) references who are not related to you and are not former employers.

Reference 1

Reference 2

Are you prevented from lawfully becoming employed in this country because of visa or immigration status?

Yes

No

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

Yes

No

Employment Experience

Start with your present or most recent job. Account for all time periods including military service, unemployment, and volunteer activities. Exclude organizational names which indicate race, color, religion, creed, sex or national origin.

Employer #1

Employer

Phone Number

Address

City

State

Zip

Start Date

End Date

Position

Duties

Starting Pay/hr

Ending Pay/hr

Are you presently employed here?

Yes

No

May we contact this employer?

Yes

No

Employer #2

Employer

Phone Number

Address

City

State

Zip

Start Date

End Date

Position

Duties

Starting Pay/hr

Ending Pay/hr

Are you presently employed here?

Yes

No

May we contact this employer?

Yes

No

Employer #3

Employer

Phone Number

Address

City

State

Zip

Start Date

End Date

Position

Duties

Starting Pay/hr

Ending Pay/hr

Are you presently employed here?

Yes

No

May we contact this employer?

Yes

No

If you have more employers to report, complete and submit this form then contact Phillips Companies directly.

Specialized Skills

Additional Information

Please state any additional information you feel may be helpful to us in considering your application.

Education

High school

Name & Address of School

Years Completed

Diploma or Degree?

Yes

No

GED

College

Name & Address

Years Completed

Diploma or Degree?

Yes

No

Graduate Professional

Name & Address

Years Completed

Diploma or Degree?

Yes

No

Other (i.e. Military)

Name & Address

Years Completed

Diploma or Degree?

Yes

No

Employment Data Record

Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status.As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply.The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this section is required by Equal Employment Opportunity Company (EEOC) guidelines. This data will be kept in a confidential file and is not considered as part of your application for employment.

This portion of the application is not required, voluntary only.

When you click the "Submit" button you will be sending all the information from this page in an email to Phillips Companies. If your information is acceptable, an associate will contact you as soon as possible.

Please Complete This Form to Submit a