PERSONAL INFORMATION
Last Name:	First Name:	Middle Intial:
	Home Phone:
Street Address:	Apartment Number:	City:
State:	Zip Code:

Do you have relatives working for this company?	No Yes	If yes, who?:
Have you ever applied for employment with Coast West Plumbing, Inc.	No Yes	If yes, when?:
Do you have the right to work in the United States?	No Yes	If hired, proof of a lawful right to work in the United States will be required.

Do you have any responsibilities, commitments or activities that would prevent you from:	Working Overtime?	No Yes
	Traveling?	No Yes
	Working specific work schedules?	No Yes

If hired, can you furnish proof of age?	No Yes	When can you report?:
How were you referred?:		Position desired?:
Salary desired?:
If hired, will you assume responsibility for arranging transportation to and from work?	No Yes

EDUCATION
High School:	Location:	Graduated:
		No Yes

Community College:	Years Completed	Units Credit	From Mo./Yr.	To Mo./Yr.	Degree Earned	Major	GPA
	1 2				No Yes
College
	1 2 3 4				No Yes
College
	1 2 3 4				No Yes
Business or Trade School
	1 2 3 4				No Yes

Honors and Awards	Professional Designations	College Expenses Earned
		%

MILITARY
Have you ever served in the United States Armed Forces?	No Yes	If yes, Branch:
If yes, give dates: to		Final Rank:

ADDITIONAL INFORMATION
Have you been convicted of a felony within the last seven years?	No Yes	If yes, explain in comment area below, in detail as to time, nature, and number of convictions. (All information provided will be taken into consideration. Conviction of a crime is not necessarily a disqualification.)
Have you used any name other than the name you are currently using while attending school or with a previous employer?	No Yes	If yes, list name(s) you've used:

EMPLOYMENT HISTORY	List all employment and periods of unemployment.

1. Company (Most recent position):	May we contact?	Job Title:
	No Yes
Address:	City:	State: Zip:

Supervisor:	Phone:	Approx number of days absent each year other than vacation:
Reason for leaving:	Full Time: Part Time:	Dates of Employment (Mo/Yr):
		From: To:

	Duties Summary:

2. Company	May we contact?	Job Title:
	No Yes
Address:	City:	State: Zip:

Supervisor:	Phone:	Approx number of days absent each year other than vacation:
Reason for leaving:	Full Time: Part Time:	Dates of Employment (Mo/Yr):
		From: To:

	Duties Summary:

3. Company	May we contact?	Job Title:
	No Yes
Address:	City:	State: Zip:

Supervisor:	Phone:	Approx number of days absent each year other than vacation:
Reason for leaving:	Full Time: Part Time:	Dates of Employment (Mo/Yr):
		From: To:

	Duties Summary:

ADDITIONAL COMMENTS:

PLEASE READ THE FOLLOWING BEFORE SUBMITTING REQUEST:

1.	I certify that all the information provided on this application is correct. I understand that omission or falsification of this information is grounds for immediate termination.
2.	I authorize Coast West Plumbing, Inc. to obtain information from previous employers, schools, DMV, credit reporting agencies, and others. I release all concerned from all liability for any damage resulting from information furnished by them.
3.	In consideration of my employment, I agree and understand that my employment and compensation can be terminated "at will," which means that I am free to quit my job at any time for any reason I deem appropriate, and that the company may terminate my employment at any time, and benefits, position, duties and other terms and conditions of employment. including the right to impose discipline of whatever type and for promotions, commendations, and the like, that this "at will" employment relationship will never change unless there is a written contract signed by me and the president of the Company, which specifically refers to and alters this "at will" relationship.