Date:

Name: (Last, First Middle/Maiden Name)

Present Address:

At present since: (Month/Day/Year)

Previous Address:

Present Telephone:

_____________________________________________________________

Date available for employment:

Are you legally eligible for employment in the United States? Yes   No

Are you related to a Stove Keepers Employee? Yes   No

If yes, employee's name and position:

Have you previously filed an application with Stove Keepers?Yes   No

Have you previously been employed by Stove Keepers?Yes   No

Job Interests:

Enter the job titles for which you are applying, or areas of interest.

References:

Provide the name and contact information of two individuals not related to you, who can provide information on your performance.

#1

Name of Reference:

Position of Reference:

Address:

Telephone:

E-mail:

Nature of relationship (teacher, minister, neighbor, friend, etc.)

How long have you known this person?

#2

Name of Reference:

Position of Reference:

Address:

Telephone:

E-mail:

Nature of relationship (teacher, minister, neighbor, friend, etc.)

How long have you known this person?

Education:

Name of School or University:

Highest grade completed:

Date of attendance:  From       To

High School or GED Yes   No

Business/Trade School Diploma/Certificate?Yes   No

College/University Degree? Yes   No

Other-Specify Yes   No

_If Yes___________________________________________________________

Other information:  Provide any other information that you feel is important for consideration of your application.  List special training, certification or license, including knowledge, skills, abilities and other qualifications you would like us to consider. 

Employment History:

Date:  From To

Position/Title:

Employer:

Address:

Number of Hours worked per week:

Supervisor:

Phone:       May we contact them? Yes   No

Salary/Wages: Start   End

Description of work:

Date:  From To

Position/Title:

Employer:

Address:

Number of Hours worked per week:

Supervisor:

Phone:       May we contact them? Yes   No

Salary/Wages: Start   End

Description of work:

Date:  From To

Position/Title:

Employer:

Address:

Number of Hours worked per week:

Supervisor:

Phone:       May we contact them? Yes   No

Salary/Wages: Start   End

Description of work:

Conditions of Employment:

Assurance:

Stove Keepers does not discriminate against any person on the basis of race, sex, color, religion, national origin, citizenship status, or handicap in any of its employment programs or activities.  We are an Equal Opportunity Employer.

Please read carefully before signing:

I certify that all information provided in this application is true and correct to the best of my knowledge.  I understand that any misrepresentation or failure to fully disclose any information requested in this application shall disqualify me from consideration, or subject me to disciplinary action up to and including dismissal in the event I am employed at the time it is discovered.  I understand that my application will remain on file for two years.  I agree that if any information of answers to questions change either before or after employment.  I will notify the Human Resources contact in writing immediately.  I authorize the superintendent to conduct reference and background checks.  I have read and understand the conditions of employment stated above.

Please type full name for signature:

Date:

Please print out, complete and fax to 878-4436, mail to PO Box 93 Temple, NH 03084 or submit electronically by clicking submit below.

If there are additional questions please e-mail keepers@stovekeeper.com