.

Phone No_________________________________Are You 18 Years Or Older?_________

Are Your Either A U.S. Citizen or An Alien Authorized To Work In The United States? Yes No

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Employment Desired

Position______________

Date You Can Start?___________

Salary Desired_______________

Are You Employed Now?_________	If So May We Inquire Of Your Present Employer? _________

Ever Applied To This Company Before__________

Where?___________

When?___________

Referred By:________________________________________________________________

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General

Subject Of Special Study Or Research Work________________________________________

__________________________________________________________________________

Special Skills________________________________________________________________

__________________________________________________________________________

Activities: (Civic, Athletic, ETC.)_________________________________________________

Exclude Organizations The Name Of Which Indicates The Race, Creed, Sex, Age, Marital Status, Color Or Nation Of Origin Of Its Members

U.S. Military or Naval Service__________________________	Rank______________________

Present Membership In National Guard or Reserves___________________________________

*The Age Discrimination In Employment Act of 1987 Prohibits Discrimination On The Basis Of Age With Respect To Individuals Who Are At Least 40 Years Of Age.

CMS Electric Cooperative, Inc.

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Former Employers            (List Below Last Three Employers, Starting With Last One First.)

Date Month And Year	Name And Address Of Employer	Salary	Position	Reason For Leaving
From
To
From
To
From
To

Which Of These Jobs Did You Like The Best?________________________________________

What Did You Like Most About This Job?___________________________________________

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References: Give The Names Of Three Persons Not Related To You, Whom You Have Known At Least One Year.

Name	Address	Business	Years Acquainted
1
2
3

"I Certify That The Facts Contained In This Application Are True And Complete To The Best Of My Knowledge And Understanding That, If Employed, Falsified Statements On This Application Shall Be Grounds For Dismissal.

I Authorize Investigation Of All Statements Contained Herein And The References Listed Above To Give You Any And All Information Concerning My Previous Employment And Any Pertinent Information They May Have, And Release All Parties From All Liability For Any Damage That May Result From Furnishing Same To You.

I Understand And Agree That, If Hired, My Employment Is For No Definite Period And May, Regardless Of The Date Of Payment Of My Wages And Salary, Be Terminated Any Time Without Prior Notice And Without Cause."

Date__________________	Signature__________________________________________________________________

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Do Not Write Below This Line

Interviewed By_______________________________________________________________	By__________________
Remarks:________________________________________________________________________________________
_______________________________________________________________________________________________

Neatness______________________________________________________	Ability_____________________________

Hired Yes No	Position______________________________	Dept.___________________

Salary/Wage___________________________________________	Date Reporting To Work_______________________
Approved By_____________________________________________________________________________________