Palmer Hamilton is an Equal Opportunity Employer and fully complies with EEOC regulations. WE support a safe and healthy work environment through pre-employment drug testing. Disabled applicants may request reasonable accommodations for completing this application.

Applicant Information

Last Name / First / M.I. / Date
Street Address / Apartment/Unit #
City / State / ZIP
Phone / E-mail Address
Date Available / Desired Salary
Position Applied for
Are you a citizen of the United States? / YES / NO / If no, are you authorized to work in the U.S.? / YES / NO
Have you ever worked for this company? / YES / NO / If so, when?
Have you ever been convicted of a felony? / YES / NO / If yes, explain

A criminal record does not constitute an automatic bar to employment and will be considered only as it substantially relates to the job in question.

Are you 18 years of age or older? / YES / NO / Referred By?
Are you currently bound by an employment agreement of any kind or a non-compete agreement? / YES / NO / If yes, explain

Education

High School: / Address
From / To / Did you graduate? / YES / NO / Degree/Courses
College: / Address
From / To / Did you graduate? / YES / NO / Degree/Courses
Other: / Address
From / To / Did you graduate? / YES / NO / Degree/Courses

Previous Employment (List present or most current employer first) “see resume” is not acceptable

Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO

References

Please list three professional references (Not Relatives)
1. Full Name / Title
Company / Phone / ( )
Address
2. Full Name / Title
Company / Phone / ( )
Address
3. Full Name / Title
Company / Phone / ( )
Address

Military Service

Branch / From / To
Rank at Discharge / Type of Discharge

List additional skills or qualifications

Disclaimer and Signature

I certify that all information submitted by me on this application is true and complete. I also understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and if I’m employed, my employment may be terminated at any time. I hereby authorize you to contact my references, employers (unless otherwise indicated), and education institutions to inquire about information that may be relevant to my employment application. I understand that no company representative, other than the president, has the authority to enter into or make employment agreements/contracts. I have read and understand the above statement.
Signature / Date

143 S. Jackson St., Ste. 1, Elkhorn, WI 53121 Phone: (262) 723-8200 Page 2 of 2