Warehouse Picker Application

Capitol Distributing Application for Employment

Last Name	First Name	Middle Initial	SSN
Address	City	State	ZIP Code
Daytime Telephone	Evening Telephone	EMail Address*
Positions(s) Applied For:		Date Available for Work?

Employment Record List your last three (3) employers, starting with the most recent.
Employer	Telephone	Date Employed From Month & Year	Date Employed To Month & Year
Address	City/State	Starting Pay Rate	Rate Per
Job Title	Immediate Supervisor & Title	Final Pay Rate	Rate Per
Reason for Leaving?	May we contact your supervisor? YesNo
Summarize the nature of the work performed and job responsibilities
Employer	Telephone	Date Employed From Month & Year	Date Employed To Month & Year
Address	City/State	Starting Pay Rate	Rate Per
Job Title	Immediate Supervisor & Title	Final Pay Rate	Rate Per
Reason for Leaving?	May we contact your supervisor? YesNo
Summarize the nature of the work performed and job responsibilities
Employer	Telephone	Date Employed From Month & Year	Date Employed To Month & Year
Address	City/State	Starting Pay Rate	Rate Per
Job Title	Immediate Supervisor & Title	Final Pay Rate	Rate Per
Reason for Leaving?	May we contact your supervisor? YesNo
Summarize the nature of the work performed and job responsibilities
UNEMPLOYMENT RECORD: Account for periods of unemployment for two (2) weeks or more during the past five (5) years.
Period	Explain
Period	Explain
Period	Explain

Have you ever been warned, disciplined, terminated, sued, or criminally charged with harassment, sexual harassment, assault, or violence in or out of the workplace? YesNo		If yes, please explain
Have you ever been convicted of a criminal offense? YesNo		If yes, please explain
Are you over 19 years of age? YesNo	Are you a citizen of the United States or do you have a valid work permit? YesNo	(Federal Law requires proof of identity and employment authorization for all new employees.)
For Driver's Only: Do you have a valid Idaho State driver's license? YesNo		Driver's License #


Educational Background	Elementary School Year Completed 5678	School Name	Major Subjects
	High School Year Completed 1234	School Name	Major Subjects
	College Year Completed 1234	School Name	Major Subjects
Other (Business, Vocational, Military)		School Name	Major Subjects

May we contact your current employer?* YesNo
Enter your initials to signify that you desire to submit an application to Capitol Distributing*			Date of Application
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