13651 Statesville Road
Huntersville, NC 28078


Contact Information:

Employment Survey:

Position Desired?

Preferred Work Schedule
 Full Time Part Time

Name and Address of Present or Last Employer

Dates of Employment and Job Title or Position

Reason for Leaving

May we contact your current employer?
 Yes No

Have you ever been terminated or been asked to resign from a job? If yes, please explain circumstances.
 Yes No

Describe Specialized Training, Military Experience and Skills:

References: Please list 3 persons who know you well. Not previous employers or relatives. Please include name, address, phone number and number of years known.

Are you 18 years or older?
 Yes No

Do you have a reliable means of transportation to travel to and from work which will allow you to consistently arrive at work on time?
 Yes No

If a valid driver's license is required for the position for which you are applying, do you have a valid driver's license?
 Yes No

Are you capable of satisfactorily performing the essential job duties required of the position for which you are applying for?
 Yes No

Please paste resume if available.