On-Line Application for Employment

PLEASE PROVIDE THE FOLLOWING CONTACT INFORMATION
Full Name
Street Address
City
State/Province
Zip/Postal Code
Work Phone
Home Phone:
Cell Phone:
E-mail
WORK EXPERIENCE
Please list your work experience, starting with your current or most recent employment.
1.  Company:
Contact Person:
Phone Number:
May we contact for reference?	YES    NO
Employed:	From:                To:
Rate of pay:
Duties or skills required:
Reason for leaving:
2.   Company:
Contact Person:
Phone Number:
May we contact for reference?	YES    NO
Employed:	From:                To:
Rate of pay:
Duties or skills required:
Reason for leaving:
3.  Company:
Contact Person:
Phone Number:
May we contact for reference?	YES    NO
Employed:	From:                To:
Rate of pay:
Duties or skills required:
Reason for leaving:
I hereby authorize Hedlund Irrigation to contact any indicated employer for references regarding my suitability for the position for which I am applying. Entered name constitutes signature. Name:    Date:
HEALTH
Have you ever had a workman's compensation injury claim? YES   NO If YES, give details for each claim:   Any current physical restrictions or impairments? YES   NO     If YES, please explain:
EDUCATION
High school graduate: YES    NO   Post secondary years completed:
PERSONAL COMMENTS