Keim Employment Application Personal Information Personal Information Full Name ? Email Phone Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Is your age under 18? Yes No Are you a U.S. citizen? If not, are you legally authorized to work in the U.S.? Yes No Job Interest Job/Position Desired Date You Could Start Work Rank in order of preference the type of schedule you desire (1, 2, 3) Questions 1 2 3 Full-Time 1 2 3 Part-Time 1 2 3 Seasonal 1 2 3 Hours you can work if unable to work full-time: Days you can work if unable to work full-time: Were you referred to work at Keim by a Keim employee? If so, write their name here. What hourly pay or salary are you seeking? Do you have any relatives who work for Keim or used to work for Keim? If yes, please list: If you are applying for a job that requires driving, do you have a valid driver's license? Yes No Education & Training Most Recent School Name School Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Years Completed Major/Minor Add another school? Yes No Second School Second Most Recent School Name School Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Years Completed Major/Minor Add another school? Yes No Third School Third Most Recent School Name School Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Years Completed Major/Minor Employment Have you been employed by Keim before? Yes No Date Employed From: Date Employed To: Have you signed a non-competition or employment agreement with a past employer? Yes No Current/Previous Employer Please list your previous employers (up to the past 10 years). This could include working for yourself, serving in the military, summer and part-time jobs. Please complete all sections for each employer. Company Name Start Date End Date Position and Duties Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming When may we contact this employer? Now After an offer of employment Reason for leaving Name and Title of Manager Telephone Number Add another company? Yes No Employer 2 Company Name Start Date End Date Position and Duties Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming When may we contact this employer? Now After an offer of employment Reason for leaving this Job/Employer Name and Title of Manager Telephone Number Add another company? Yes No Employer 3 Company Name Start Date End Date Position and Duties Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Wrapper When may we contact this employer? Now After an offer of employment Reason for leaving this Job/Employer Name and Title of Manager Telephone Number Additional Information Attach Resume and/or Cover Letter (optional) One file only.100 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. State any additional information you feel may be helpful to us in considering your application. This could include any specialized training or courses you have completed that will aid in evaluating your qualifications for the position you are seeking. (Example: If applying for a clerical position, note training such as word processing, typing, computer, hardware, software, etc.) Applicant Release & Acknowledgement I understand that any employment with Keim would be "at-will," meaning that I or Keim could end my employment at any time, or for any reason consistent with applicable state or federal laws. I permit Keim to conduct a full background investigation of my work and educational history and to confirm all information given on this application and during interviews is true. I release Keim, and its representatives or agents, from any liability that might result from such investigation. I permit all individuals, schools, employers and companies named in this employment application to provide any requested information and release them from all liability for providing the requested information. I will complete any post-offer physical evaluations that Keim may require including testing for illegal or unauthorized drugs or other substances. I understand that any offer of employment is contingent upon my successful passing any physical evaluation requirements and background investigation. I certify that all statements in this completed application are true and I understand that any falsification or willful omission are enough cause for dismissal from employment or refusal to hire. My signature below confirms that I have read and understand the entire application and that I agree to the terms and conditions outline above. Signature Sign above