Employment Application Simplex, Inc. is an Equal Opportunity Employer. Fill in as much information as possible. If additional information is required Simplex will contact you.

Job Applied for:

PERSONAL INFORMATION

Name (Last, First): Address: City: State: Zip Code: Phone: E-Mail: References (Exclude Relatives): 1. Name: Address: Phone: 2. Name: Address: Phone: 3. Name: Address: Phone: Did you serve in the military?YesNo Branch(es): Dates of Service: Service Number: YesNo............Active Duty? YesNo............National Guard? YesNo............Reserves? Do you have a valid driver's license?YesNo State: License Number: Have you ever been convicted of a felony?YesNo (Conviction will not bar employment, but will be considered in relation to specific job requirements.) Do you have any objections to working overtime?YesNo (Because of the critical nature of the applications of our equipment, when overtime is needed it is not voluntary. Employees are required to work overtime as needed.)

Employment History
List all jobs you have held starting with your present or last job. Include Military Service. Salary includes monthly, weekly, or hourly pay only. Do not include overtime, shift premium, or bonuses.

PRESENT OR LAST JOB

Date Started: Date Left: Starting Salary: Ending Salary: Company Name, Address, City, State, and Zip Code: Name of Immediate Supervisor: Reason for Leaving: Your Duties and Responsibilities at this Job:

JOB No. 2

Date Started: Date Left: Starting Salary: Ending Salary: Company Name, Address, City, State, and Zip Code: Name of Immediate Supervisor: Reason for Leaving: Your Duties and Responsibilities at this Job:

JOB No. 3

Date Started: Date Left: Starting Salary: Ending Salary: Company Name, Address, City, State, and Zip Code: Name of Immediate Supervisor: Reason for Leaving: Your Duties and Responsibilities at this Job:

Education
Check highest grade completed:
9101112131415161718

List the schools you have attended. Include business, vocational, and military schools.

HIGH SCHOOL
Date Started:	Date Left:	Name, Address, City, State, and Zip Code:
COLLEGE, BUSINESS, VOCATIONAL, or MILITARY SCHOOL NO. 1
Date Started:	Date Left:	Name, Address, City, State, and Zip Code: Degrees / Certificates Earned:
COLLEGE, BUSINESS, VOCATIONAL, or MILITARY SCHOOL NO. 2
Date Started:	Date Left:	Name, Address, City, State, and Zip Code: Degrees / Certificates Earned:
COLLEGE, BUSINESS, VOCATIONAL, or MILITARY SCHOOL NO. 3
Date Started:	Date Left:	Name, Address, City, State, and Zip Code: Degrees / Certificates Earned:

ADDITIONAL INFORMATION

List any information no listed above that would be helpful in condsidering you for this position.