CONFIDENTIAL

EMPLOYEE HISTORY

NAFA CONSULTANTS & EMPLOYMENT AGENCY

2 WEST MAIN ST, AVON PARK, FLORIDA 33825 TEL 863-453-3156

Employee Name		Status (Seasonal)	Part Time On Call			Security Clearance				\
						Level		Date Granted
Social Security No. Date of Birth Marital Status V		Sex Employment Date Prior Employment D Yes D No				1-9 Documentation Completed? D Yes D No j
Address		State Zip		Telephone						\
Change Date	Address Change City	State Zip		Telephone
MARITAL STATUS		State Zip		Telephone
Date of Birthday		State Zip		Telephone
r Years of SERVICE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 V^ Service		6 17 18 19 20	21 22 23 24 25 26 27 28	29	30		31 32 3	5 34 35	36 3	7 3§\

EN CASE OF EMERGENCY — CONTACT:

Name	Relationship	Telephone No.	Address "\
Name	Relationship	Telephone No.	Address
Doctor	Telephone Nos.		Address
Doctor	Telephone Nos.		Address
Emergency Medical Information (Allergies, Medication, etc.)

TAX INFORMATION

Federal (W-4) Exemptions					State/City Exemptions
No.
Date					— •
f Other Deductions ^\
Type	Credit Union	Christmas Club	Additional Ins.	Other Medical	Employee Fund
Amt.
Date V

Insurance	Date Eligible	Date Enrolled	Date Withdrawn	Retirement	Date Eligible	Date Enrolled	Date Withdrawn^
Medical - self				Co. Pension Plan
Medical - family				Union Pension Plan
Dental				401(K) Plan
Eye care				Other			'
Disability				Options	Date Eligible	Date Enrolled	Date Withdrawn
Life				Profit Sharing
				Stock Plan
				Union
				Credit Union
				Other

Application for Employment

NATIONAL CONSULTANT AND EMPLOYMENT AGENCY
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
(PLEASE PRINT)
Position(s) Applied For			Date of Application
How Did You Learn About Us? D Advertisement D Employment Agency	D Friend D Walk-In PI Relative D Other
Last Name First Name Middle Name
Address Number Street City State Zip Code
Telephone Number(s)		Social Security Number

⮚ Yes ⮚ No

⮚ Yes ⮚ No

_________________

⮚ Yes ⮚ No ______________

⮚ Yes ⮚ No

⮚ Yes ⮚ No __________

__________________

If yes, give date If yes, give date

If you are under 18 years of age, can you provide required proof of your eligibility to work?

Have you ever filed an application with us before?

Have you ever been employed with us before?

Are you currently employed?

May we contact your present employer?

⮚ Yes ⮚ No

⮚ Ye ⮚ No

⮚ Yes ⮚ No

⮚ Yes ⮚ No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Proof of citizenship or immigration status will be required upon employment.

On what date would you be available for work?

Are you available to work: ⮚ Full Time ⮚ Part Time ⮚ Shift Work Temporary⮚
Are you currently on "lay-off¹ status and subject to recall?
Can you travel if a job requires it?
Have you been convicted of a felony within the last 7 years?

Conviction will not necessarily disqualify an applicant from employment.

If yes, please explain ______________________________________________________________________________________________________________________________

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer		Dates Employed		Work Performed
		From	To
Address
Telephone Number(s)		Hourly Rate/Salary
		Starting	Final
Job Title	Supervisor
Reason for Leaving
Employer		Dates Employed		Work Performed
		From	To
Address
Telephone Number(s)		Hourly Rate/Salary
		Starting	Final
Job Title	Supervisor
Reason for Leaving
Employer		Dates Employed		Work Performed
		From	To
Address
Telephone Number(s)		Hourly Rate/Salary
		Starting	Final
Job Title	Supervisor			—
Reason for Leaving
Employer		Dates Employed		Work Performed
		From	To
Address
Telephone Number(s)		Hourly Rate/Salary
		Starting	Final
Job Title	Supervisor
Reason for Leaving

If you need additional space, please continue on a separate sheet of paper.

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability
or other protected status:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EDUCATION AND TRAINING

Major

Specialization

/Elem~7

Skilled Training

⮚YES ⮚NO

Jr. U.S. J

High School

1 I 2 34

College

1 2 3

4567

Other Special Skills and Training

DEPENDENTS

/"Name	Relationship		Sex		Date of Birth	Social Security Number ^
Name	Relationship		Sex		Date of Birth	Social Security Number
Name	Relationship		Sex		Date of Birth	Social Security Number
Name	Relationship		Sex		Date of Birth	Social Security Number
Name	Relationship		Sex		Date of Birth	Social Security Number
Name ^	Relationship		Sex		Date of Birth	Social Security Number J
RELATIVES AND FRIENDS EMPLOYED AT COMPANY
/Name		Relationship		Name Relationship ~\
Name		Relationship		Name Relationship
Name V		Relationship		Name Relationship J

TERMINATION RECORD (FILE EXIT INTERVIEW PAGE IN ADJACENT POCKET)

Interview Date

⮚

Resignation ⮚ Dismissal

Reason for Separation

Last Day Worked

Date

Exit Interview Completed D Yes D No

COMPLETE COBRA INFORMATION ON FRONT

RECORD OF EMPLOYEE CONVERSATIONS

DATE	Reason For Conference ~\
Date	Reason For Conference
Date	Reason For Conference
Date	Reason For Conference
Date	Reason For Conference
Date	Reason For Conference
Date	Reason For Conference
Date	Reason For Conference
Date	Reason For

Additional Information

Other Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

Specialized Skills Check Skills/Equipment Operated

_CRT _PC

_Calculator

__Typewriter

Production/Mobile Machinery (list):

_Fax

_Lotus 1-2-3 _PBX System _Word

Other (list):

State any additional information you feel may be helpful to us in considering your application.

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or

Without a reasonable accommodation, the activities involved in the

Job or occupation for which you have applied? A description of the

Activities involved in such a job or occupation is attached. __YES __NO

References

1. ( )
	(Name)	Phone #
2.	(Address)	( * )
	(Name)	Phone #
3.	(Address)	( }
	(Name)	Phone #
(Address)

FOR PERSONNEL DEPARTMENT USE ONLY
Position(s) Position(s)	Applied For Is Open: ___ Yes ___ No Considered For:
	Date

NOTES:

REV 10/2003