EBEN'S HEARTH APPLICATION FOR EMPLOYMENT
PLEASE NEATLY PRINT THE FOLLOWING INFORMATION

NAME_______________________________________________________ DOB____________________
                last                                      first                                      middle initial

DATE_________________PHONE #_________________________ S.S.#__________________________

PRESENT ADDRESS____________________________________________________________________

PERMANENT ADDRESS________________________________________________________________

POSITION SEEKING_____________________________________

Number  of  hours  desired____________________                      Wage  Desired____________________

Do  you  own  a  car  and  is  it  in  your  possession  for  use  now? ________
                                                                                                                                     ^{M/YR             M/YR}
MOST RECENT EMPLOYER_______________________________________ From______  To _______
SUPERVISOR___________________________________________ Phone  #_______________________
Position with Company___________________________________________________ Wage ____________
Reason For Leaving______________________________________________________________________

2ND MOST RECENT EMPLOYER________________________________ From______  To ___________
SUPERVISOR________________________________________ Phone #___________________________
Position with Company________________________________________________ Wage________________
Reason For Leaving_______________________________________________________________________

3RD MOST RECENT EMPLOYER________________________________ From______  To ___________
SUPERVISOR________________________________________ Phone #___________________________
Position with Company________________________________________________ Wage________________
Reason For Leaving_______________________________________________________________________

EDUCATION
High  School  Graduate? Y____ N____
College  Graduate?         Y____ N____
Are  you  currently  continuing  your  education? Y____ N____
If  Yes  School______________________________ Major______________________ GPA_____________
How  long  do  you expect  to  be  in  the  Potsdam  area?___________

REFERENCES-other than relatives

Name_______________________________________________ Yrs._________ Phone #_______________

Name________________________________________________ Yrs_________ Phone #_______________

Name________________________________________________ Yrs_________ Phone #_______________