APPLICANT REGISTRATION FORM     (DES-511)

If you do not wish to use the Internet E-mail you may submit the requested information by:

1. Visiting - 1610 University Ave - Knoxville TN 37921

2. Mailing Address – 1610 University Ave, Suite 106-Knoxville, TN 37921

3. Package Service - 1610 University Ave, Suite 106 - Knoxville TN 37921

4. FAX information to 865-594-6266

PLEASE COMPLETE ALL AREAS OF INFORMATION:

Social_Secuity_#(Required)		(xxx-xx-xxxx)
Name_(Required)	(Last,_First_M.)
E-mail	(Optional)
Mailing_Address_(Required)
City_(Required)
State_(Required)	(xx)
Zip_(Required)	(xxxxx-xxxx)
Home_Phone	(xxx-xxx-xxxx)
Other_Phone	(xxx-xxx-xxxx-ext)

Ethnic_Group_Information:

            Hispanic_or_Latino      Yes No

Race:

White   Black   Asian   American_Indian   Hawaiian/Pacific_Islander

Gender_(Required):   Male Female

Date_of_Birth_(Required)

(mm/dd/yyyy)

Education_(Required)_(Highest_Full_Year_Completed):

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

 

Post_Secondary_Degree/Certification:

(Associate's, Bachelor's, CPA, MD)

US Citizen_(Required):        Yes No    

 I am a student:      Yes No

I am working:          Yes No

I am willing to relocate:     Yes No

I have an automobile:        Yes No   

I have other transportation:     Yes No      

If Yes - Type   (Motor Cycle, Truck, Bus, ???)

I have an occupational license:      Yes No

If Yes - Type   (Child Care ,Barber ,Nurse, ???)

I have a drivers license:      Yes No

Type/Class     A     B     C     D

I have a commercial drivers license:      Yes No

Endorsements     C   F   H   P   S   T   X

What shift do you prefer?

(1^st, 2^nd, 3^rd, any shift)

What starting range will you accept?

(Dollars/Hr, Day, Wk, Mo, Yr)

How far are you willing to commute (one way)?

(Miles)

Machines or tools you can use:

(Torch, Lathe, Computer, Fork Lift, CNC Mill, etc)

Special knowledge/abilities:

(Word Perfect, AutoCad, COBAL, etc)

Special training:

(LPN, Bartender, etc)

List The Type Work You Desire (Required):

#1 Job Desired
Months Experience as #1 Above
#2 Job Desired
Months Experience as #2 Above
#3 Job Desired
Months Experience as #3 Above

List Work History starting with your last job.
(List those that are most important and lasted the longest)

Work History # 1

#1_Company
#1_Address
#1_City
#1_State	(xx)
#1_Zip_Code	(xxxxx-xxxx)
#1_Phone	(xxx-xxx-xxxx-ext)
#1_Start_Date	mm/dd/yyyy
#1_End_Date	mm/dd/yyyy
#1_Rate_of_Pay	($/Hr, $/Wk, $/Mo, $/Yr, Commission, Piece Rate, etc)
#1_Job_Duties

 

Work History # 2

#2_Company
#2_Address
#2_City
#2_State	(xx)
#2_Zip_Code	(xxxxx-xxxx)
#2_Phone	(xxx-xxx-xxxx-ext)
#2_Start_Date	mm/dd/yyyy
#2_End_Date	mm/dd/yyyy
#2_Rate_of_Pay	($/Hr, $/Wk, $/Mo, $/Yr, Commission, Piece Rate, etc)
#2_Job_Duties

 

Work History # 3

#3_Company
#3_Address
#3_City
#3_State	(xx)
#3_Zip_Code	(xxxxx-xxxx)
#3_Phone	(xxx-xxx-xxxx-ext)
#3_Start_Date	mm/dd/yyyy
#3_End_Date	mm/dd/yyyy
#3_Rate_of_Pay	($/Hr, $/Wk, $/Mo, $/Yr, Commission, Piece Rate, etc)
#3_Job_Duties

 

The following information requested is voluntary and is for statistical purposes only:

Do you have a disability or condition that limits your ability to work?

Yes No

If you answered yes will you need any type of accommodation to work?

Yes No

 

Complete this section if you are a Military Veteran (proof of Veteran Status may be required):

         Branch: (Army,USAF,Navy,USMC,USCG) (Required if Veteran)

Rank at discharge:  (IE: E3,E7,W4,O4,O6) (Required if Veteran)

Dates of Service:   FROM(mm/dd/yy)-TO(mm/dd/yy) (Required if Veteran)

          Type of Discharge:   (Honorable,General,etc.) (Required if Veteran)

 

Did you serve on ACTIVE DUTY for OTHER THAN TRAINING for 181 DAYS or longer? (Required if Veteran)

Yes No

Do you have a Campaign Badge/Expedition Badge? (Required if Veteran)

Yes No

Do you have a service connected disability? (Required if Veteran)

Yes No

If you answered Yes, what is the disability percentage? (Required if Veteran)

(xx %)

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

You may make a short comment/note here:

 

YOU HAVE COMPLETED THE FORM.
PLEASE SUBMIT OR RESET BELOW.