Non-Driver Application

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Applicant Information

Full Name*

First Middle Last

Phone*

Email*

Current Address*

Street Address Address Line 2 City State ZIP Code

Employment Desired

Desired Position*

Desired Salary*

Date Available for Work*

Are you employed now?*

Yes

Do you have the legal right to work in the United States?*

Yes

Have you ever been employed by this organization before?*

Yes

If yes, list dates of employment*

Industry Experience

Industry Experience*

Summarize any industry experience that you may have that would be relevant to this position, or any other relevant skills you possess.

Employment History

Current (Most Recent) Employer

Company Name*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisors Name & Title*

Position Held*

Salary*

Dates Employed*

From

Reason for Leaving?*

May we contact your previous supervisor for a reference?*

Yes

Do you need to list another (second) employer?*

Yes

Second (Most Recent) Employer

Company Name*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisors Name & Title*

Position Held*

Salary*

Dates Employed*

From

Reason for Leaving?*

May we contact your previous supervisor for a reference?*

Yes

Do you need to list another (third) employer?*

Yes

Third (Most Recent) Employer

Company Name*

Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisors Name & Title*

Position Held*

Salary

Dates Employed*

From

Reason for Leaving?*

May we contact your previous supervisor for a reference?*

Yes

Do you need to list another (fourth) employer?*

Yes

Fourth (Most Recent) Employer

Company Name*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisors Name & Title*

Position Held*

Salary*

Dates Employed*

From

Reason for Leaving?*

May we contact your previous supervisor for a reference?*

Yes

Education

List of Education History*

Please enter each school that you attended, including high school, college, and trade schools if applicable. (Click the + button to add a new row)

School Name

Address

Years Attended

Did You Graduate?

Subjects Studies

Other Qualifications*

Please list any other qualifications which you have and which you believe would be important for consideration by the company pertaining to this application.

References

Please provide the Name, address, and telephone of four references who are not related to you and you have known for at least five years.

Reference 1*

Name

Relationship

Company

Years Acquainted

Address

Phone Number

Reference 2*

Name

Relationship

Company

Years Acquainted

Address

Phone Number

Reference 3*

Name

Relationship

Company

Years Acquainted

Address

Phone Number

Reference 4*

Name

Relationship

Company

Years Acquainted

Address

Phone Number

Acknowledgement

EQUAL EMPLOYMENT OPPORTUNITY STATEMENT

Prospective applicants will receive consideration without discrimination because of race, color, religion, sex, national origin, age, marital or veteran status, non-job-related medical conditions or handicaps, or any other legally-protected status.

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

Signature*

Full Name*

Date*

Resume/File Upload (optional)

If you have a resume or additional documents you would like to attach, please do so here. This is not required.

Drop files here or

Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 5 MB, Max. files: 5.

Your information is processed securely, and is never shared, distributed, or sold to any third parties. By providing a telephone number and submitting the form you are consenting to be contacted by voice or SMS text message. Message frequency may vary. Message & data rates may apply. Reply STOP to opt-out, Reply HELP for more information.

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We proudly serve a wide region of North Carolina, covering communities in Rockingham, Guilford, Stokes, and Forsyth Counties, including Madison, Mayodan, Eden, Reidsville, Walnut Cove, Stokesdale, Summerfield, and Oak Ridge.

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