Application

Contact Information – Step 1 of 7

*First Name:	Middle Name: *Last Name:
Email Address:
*Address:
*City:	State: ZIP:
*Home Phone:	888-888-8888
Cell/Other Phone:	888-888-8888
*May we contact you at work?	Yes No
Work Phone:	888-888-8888
Best Time to Call:

General Information – Step 2 of 7

*Are you under 18?	Yes No
(If you are under 18, you will be required to furnish a work permit as a condition of employment.)
*Have you filed an application with WRMC before?	Yes No
If yes, give date:	mm/dd/yyyy
*Have you ever been employed here before?	Yes No
If yes, give dates:	From: To: mm/dd/yyyy
*Do any of your relatives work for WRMC?	Yes No
If yes, give name & relationship:
*Are you legally eligible for employment in the U.S.?	Yes No
(Proof of U.S. citizenship or immigration status will be required.)
*Date available for work:	mm/dd/yyyy
*Type of employment desired:	Full Time Part Time Temp/PRN
*Which shifts would you consider working:	First Shift Second Shift Third Shift Weekends
*Will you travel if the job requires it?	Yes No
*Will you work overtime if required?	Yes No
*Will you undergo post-offer screening?	Yes No
*Have you ever been convicted of a crime?	Yes No
(You must consent to a criminal record check as a condition of employment.)

Employment History – Step 3 of 7

List your last three employers, assignments, or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in the comments section below.

Employer 1 (most recent)
*Company Name:
*Address:
*City:	State: ZIP:
*Phone:	888-888-8888
*May we contact for reference?	Yes No
*Job Title:
*Dates Employed – Start:	End:
*Immediate Supervisor:	Title:
*Starting Salary/Hourly Rate:
*Final Salary/Hourly Rate:
*Reason for Leaving:
*Duties & Responsibilities:

[ Add an Employer ]

Employer 2 [ Remove ]
Company Name:
Address:
City:	State: ZIP:
Phone:	888-888-8888
May we contact for reference?	Yes No
Job Title:
Dates Employed – Start:	End:
Immediate Supervisor:	Title:
Starting Salary/Hourly Rate:
Final Salary/Hourly Rate:
Reason for Leaving:
Duties & Responsibilities:

[ Add an Employer ]

Employer 3 [ Remove ]
Company Name:
Address:
City:	State: ZIP:
Phone:	888-888-8888
May we contact for reference?	Yes No
Job Title:
Dates Employed – Start:	End:
Immediate Supervisor:	Title:
Starting Salary/Hourly Rate:
Final Salary/Hourly Rate:
Reason for Leaving:
Duties & Responsibilities:


Comments:	(Explain any gaps in employment)

Education & Qualifications – Step 4 of 7

Skills & Qualifications:
Summarize special skills and qualifications acquired from employment
or other experiences that qualify you for work with our company.

Professional Licenses/Certifications & Valid Dates:
Please enter currently valid licence/certificate numbers and valid dates.
You will be required to supply a copy of any required licenses or certificates.

Educational Background

*Please select the highest level of education reached.

Please list the schools you have attended, along with degrees received, major/minor, and completion dates where applicable, starting with the most recent.

School 1 (most recent)

Name:	Type:	Degree Received:
	Date Completed:	Major/Minor:

School 2

Name:	Type:	Degree Received:
	Date Completed:	Major/Minor:

School 3

Name:	Type:	Degree Received:
	Date Completed:	Major/Minor:

School 4

Name:	Type:	Degree Received:
	Date Completed:	Major/Minor:

School 5

Name:	Type:	Degree Received:
	Date Completed:	Major/Minor:

Foreign Languages

If you are multilingual, list languages, other than English,
and check the boxes that describe your skill level.

Language 1:

Proficiencies: Read Write Speak

Language 2:

Proficiencies: Read Write Speak

Language 3:

Proficiencies: Read Write Speak

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Affiliations, Awards & Accomplishments – Step 5 of 7

List professional, trade, business, or civic associations and any offices held.
Organization:
Offices Held:

Organization:
Offices Held:

Organization:
Offices Held:

List special accomplishments, publications, or awards:

List any additional information you would like us to consider:

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References – Step 6 of 7

List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you.

*Name:
*Phone:
*Years Known:
*Type of Reference:

*Name:
*Phone:
*Years Known:
*Type of Reference:

*Name:
*Phone:
*Years Known:
*Type of Reference:

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Terms – Step 7 of 7

Please read carefully:

It is understood and agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurance to the contrary.

I give WRMC the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. This application is current for only 90 days. At the conclusion of this time, if I have not heard from WRMC and still wish to be considered for employment, it will be necessary for me submit a new application.

I consent to any post-offer health screening required by the facility at any time to determine my ability to perform the duties of my job or other jobs with the facility and I understand that my employment may be conditioned upon satisfactorily completing the employment process. I understand that I will be required to satisfactorily complete an alcohol/drug screening and consent to a criminal record check as a condition of employment.

Contact Information – Step 1 of 7

Next »

General Information – Step 2 of 7

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Employment History – Step 3 of 7

List your last three employers, assignments, or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in the comments section below.

Employer 1 (most recent)

[ Add an Employer ]

Employer 2

[ Remove ]

[ Add an Employer ]

Employer 3

[ Remove ]

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Education & Qualifications – Step 4 of 7

Educational Background

Foreign Languages

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Affiliations, Awards & Accomplishments – Step 5 of 7

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References – Step 6 of 7

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Terms – Step 7 of 7

Please read carefully:

* I accept the above terms.

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Click "Review Application" below to review your information.

WRMC is an equal opportunity employer. WRMC does not discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

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