Kentucky Supply Job Employment Application
All information submitted on this form will remain completely confidential.
Notice: This is a drug free company; You will be required to take a company
physical, which includes a drug test, to be employed here. Drug tests are also
administrated at random and post accidents.

POSITION APPLIED FOR: 
MINIMUM STARTING PAY: 

NAME: 
ADDRESS: 
CITY:  STATE:   ZIP: 

HOME PHONE:
CELL PHONE: 
EMAIL ADDRESS: 

SPOUSE'S NAME: 
SPOUSE'S EMPLOYMENT:  
SPOUSE'S EMP. PHONE:   


SSN:  

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EDUCATION
SCHOOL NAME & LOCATION

ELEMENTARY  
HIGH SCHOOL  
VOC/TECH/COLLEGE   
      MAJOR  

HIGHEST GRADE COMPLETED:  

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BACKGROUND

HAVE YOU EVER BEEN CONVICTED OF A FELONY? 
          IF YES, EXPLAIN: 

HAVE YOU EVER BEEN CONVICTED OF A DUI IN THE PAST 5 YEARS?       DATE: 

DO YOU HAVE A VALID KENTUCKY DRIVER'S LICENSE? 

DO YOU HAVE A FEAR OF HEIGHTS? 


DO YOU HAVE A FEAR OF CLOSE PLACES? 


ARE YOU UNDER A DOCTOR'S CARE WHICH REQUIRES MEDICATION? 

   IF YES,         NAME OF MEDICATION: 

           REASON UNDER DOCTOR'S CARE: 

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EMPLOYMENT EXPERIENCE
			
			*Start with your present or last job. Feel free to include any job related

			military assignments and volunteer activities. You may exclude orgranizations

			which indicate race, color, religion, gender, national origin, handicap, or 

			other protected status.
EMPLOYER #1:

NAME:

ADDRESS:

CITY: STATE: ZIP:

TELEPHONE #:

SUPERVISOR'S NAME:

ENDING JOB TITLE:

DATES EMPLOYED - FROM: TO:

SALARY / HOURLY RATE - STARTING: FINAL:

WORK/SKILLS PERFORMED:

REASON FOR LEAVING:

EMPLOYER #2:

NAME:

ADDRESS:

CITY: STATE: ZIP:

TELEPHONE #:

SUPERVISOR'S NAME:

ENDING JOB TITLE:

DATES EMPLOYED - FROM: TO:

SALARY / HOURLY RATE - STARTING: FINAL:

WORK/SKILLS PERFORMED:

REASON FOR LEAVING:

EMPLOYER #3:

NAME:

ADDRESS:

CITY: STATE: ZIP:

TELEPHONE #:

SUPERVISOR'S NAME:

ENDING JOB TITLE:

DATES EMPLOYED - FROM: TO:

SALARY / HOURLY RATE - STARTING: FINAL:

WORK/SKILLS PERFORMED:

REASON FOR LEAVING:


PERSONAL REFERENCES (OF NO RELATION TO YOU)

REFERENCE #1:

NAME:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE:

CELL PHONE:

REFERENCE #2:

NAME:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE:

CELL PHONE:

REFERENCE #3:

NAME:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE:

CELL PHONE:


IN CASE OF AN EMERGENCY, PLEASE GIVE NAME, ADDRESS, CONTACT #'S OF PERSON TO CONTACT:

NAME:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE:
CELL PHONE:
WORK PHONE:

BY CHECKING THIS CHECK BOX YOU AGREE TO: AUTHORIZE KENTUCKY SUPPLY, LLC. TO CONTACT ANY AND ALL
REFERENCES NECESSARY TO OBTAIN INFORMATION FOR THE PURPOSE OF POSSIBLE EMPLOYMENT, INCLUDING
BUT NOT LIMITED TO THE REFERENCES LISTED ABOVE. I ALSO AUTHORIZE KENTUCKY SUPPLY, LLC. TO PERFORM
BACKGROUND AND/OR CREDIT CHECKS WITH ANY OUTSIDE AGENCY KENTUCKY SUPPLY, LLC. MAY ELECT TO UTILIZE.

How did you here about our job openings:

When done, please or