Franklin Imaging

Employment Application

All statements made by the applicant on this employment application are subject to verification by Franklin Imaging. Any exaggerated, false, misleading or omitted statements may be cause for disqualification from further consideration for employment and/or subsequent termination from employment. EOE/M/F/D/V

APPLICATION INFORMATION

First Name Last Name Address 1 Address 2 City State Zip Phone Email Address Date Available Which position are you applying for? What school district do you live in? Are you a citizen of the United States? Yes   No If no, are you authorized to work in the U.S.? Yes   No Are you 18 years of age or older? Yes   No Have you ever worked for this company? Yes   No If yes, when? Have you ever been convicted of a crime (misdemeanor or felony)? Yes   No If yes, explain Are you able to lift up to 50 lbs. on a regular basis? Yes   No If no, please explain. For positions that require driving a company vehicle – Do you have a valid driver’s license? Yes   No

For insurance purposes, a “Clean Driving Record” is defined as follows:
No more than 4 points for moving violations and/or accidents within the last 3 years.
No DUI’s or Suspensions (of any kind) within the last 5 years.

Do you have a clean driving record? Yes   No If no, please explain.

EDUCATION

High School High School Address Did you graduate from high school? Yes   No High School Degree
College College Address Attended from to Did you graduate from college? Yes   No College Degree
Other Address Attended from to Did you graduate? Yes   No Degree

REFERENCES

Please list three professional references.

Full Name Relationship Company Phone Address
Full Name Relationship Company Phone Address
Full Name Relationship Company Phone Address

PREVIOUS EMPLOYMENT

Company Address Phone Job Title Responsibilities Dates of Employment from to Starting Salary Ending Salary Reason for Leaving May we contact your previous supervisor for a reference? Yes   No
Company Address Phone Job Title Responsibilities Dates of Employment from to Starting Salary Ending Salary Reason for Leaving May we contact your previous supervisor for a reference? Yes   No
Company Address Phone Job Title Responsibilities Dates of Employment from to Starting Salary Ending Salary Reason for Leaving May we contact your previous supervisor for a reference? Yes   No

MILITARY SERVICE

Branch Served from to Rank at Discharge Type of Discharge If other than honorable, explain