Mid-America Car, Inc. Application for Employment

1. I certify that I have had the opportunity to read the applicant instructions prior to filling out the application.
I also certify that I agree to the terms of the applicant instructions. Yes
2. Today's Date:
3. Employee Name (First, MI, Last):
4. Social Security Number: - -
5. Home Phone:
6. Work Phone:
6a. Extension:
7. Current Address:
7a. City, State, Zip Code:
8. Previous Address:
8a. City, State, Zip Code:
9. I certify that I have had the opportunity to read the applicant note prior to filling out the application. I also certify that I agree to the terms of the applicant note. I certify
10. E-Mail Address:
11. For which positions are you applying for? Select all that apply:
Locomotive MechanicSupervisorRepairerPainterLocomotive ElectricianGeneral ClerkInventory Clerk
12. What date would you be available to start?
13. What category of employment would you prefer? Select all that apply:
Full-TimePart-TimeTemporaryLaborpool
14. For which schedules are you available? Select all that apply
WeekdaysWeekendsEveningsNightsOvertimeShiftOther - Note on comments
15. What was the highest grade that you completed? —Please choose an option—10 - Sophmore11 - Junior12 - SeniorSome CollegeCollege GraduateSome Trade SchoolTrade School Graduate
16. High School Info.

Did you graduate? —Please choose an option—YesNo
17.College Info:

Did you graduate? —Please choose an option—YesNo
Degree you graduated with:
18.Other School Info:
Did you graduate? —Please choose an option—YesNo
Degree you graduated with.
19. List states and counties of residence for the past seven years:




20. List any additional names or social security numbers that you may have used other than those listed on this page.



21. List any felony convictions and time served in prison in the last seven years. (State the incident, city, state, and charge.) In accordance with company policy this information will be reviewed for job relatedness and time since last conviction.



22. Select languages that you are fluent in:
EnglishSpanishFrenchArabicOther - Noted in comments
23. Please enter the following information about your driver's license.
If the job you are applying for requires a license, do you carry that license? —Please choose an option—YesNo
Driver's License Number:
Class of driver's license:
State of issue:
24. Describe any moving violations you may have on your driver's license.



25. Please list any other skills, licenses, or certificates that may be job related or that you feel would be of value to this job or company.




26. Have you had a chance to review the job descriptions or had the requirements of the job explained to you? —Please choose an option—YesNo
27. Do you understand these requirements? —Please choose an option—YesNo
28. Would you be able to perform these requirements with or without any reasonable accommodations? —Please choose an option—YesNo
29. Most Recent Employer:
Company Name:
Phone:
Dates employed:
Job Title:
Supervisor Name:
Duties:
Duties:
Duties:
Reason for leaving:
30. Are you currently working for this employer? —Please choose an option—YesNo
31. If yes, may we contact? —Please choose an option—YesNo
32. Previous Employer:
Name, City, State:
Phone:
Dates employed:
Job Title:
Supervisor Name:
Duties:
Duties:
Duties:
Reason for leaving:
33. Previous Employer:
Name, city, state:
Phone:
Dates employed:
Job Title:
Supervisor Name:
Duties:
Duties:
Duties:
Reason for leaving:
34. Please enter all of your information for your first reference.
Name of reference:
Street Address:
City, State, Zip code:
Phone Number:
Years Known:
Relationship:
35. Please enter all of your information for your second reference.
Name of reference:
Street Address:
City, State, Zip code:
Phone Number:
Years Known:
Relationship:
36. Comments

37. I agree to the conditions set forth in the certification & release statement. —Please choose an option—Yes
38. I agree to the terms in the Statement of social security number to be used as signature. —Please choose an option—Yes