WESSTERN MA
AINE SUPPLY CO., INC. BOX 69 * 33 C
CROSS ST. * B
BETHEL, ME 0
04217 P.O. B
HONE: 207‐824‐2139 * FA
AX: 207‐824‐3
3554 PH
www.westternmainesup
pply.com
E
EMPLOYME
ENT APPLICATION
Name: ____________________
_______________________________ Date: ________________________________
_______________________________
Addrress: __________________
Town: _______________________________
Statee: __________ Zip: ______
______ Telep
phone Numbeer: ____________________ Social Securrity #: ________________
Posittion Applied FFor: _______
_____________________________ Special Licenses: __________________________________
List sskills related tto this positio
on: ___________________________________________
_________________________________ ou are applyin
ng for a Drive
er’s Position: If yo
___________________ State _________________ Driveers License # ___________
n the precedin
ng two years resulted in a positive test result or a reefusal to Has any pre‐employment test conducted in
test?? YES ________ NO __
______ List aany motor veehicles traffic violations forr the past 12 months: _____________________________________________ ___________________________
____________________________________________________________________________ Havee you ever beeen convicted of a felony? _________
If yess, Please Explain: _______
______________________________________________________________________________ ___________________________
______________________________________________________________________________ Are yyou employed
d now? ____
________ Wh
here: _____________________________________________________________ May we contact yyour current e
employer? __________ what date wou
uld you be avvailable for wo
ork: ______________________ On w
List previous employment (Beginning with most recent) plus Job Titles: EMPLOYMENT JOB TITLE DATES PERSONAL REFERENCES: (List at least 3 personal references.)