Personal Information
   Name (Last Name First)  Social Security #
   Present Address      
   City                                State       Zip
   Permanent Address  
   City                                State       Zip
   Home Phone               Cell/Pager  E-mail 

  Employment Desired
   Position applied for:  Membership sales Fitness Instructor Childcare Front Desk Aerobics Instructor Administrative     Date you can start:
   Salary desired         Are you employed?  Yes      No
   If so what is your current title?     

  Education History
   School   Grammar School High School College Trade Business Correspondence    Name & location of school 
   School   High School College Trade Business Correspondence Grammar School    Name & location of school 
   School   College Trade Business Correspondence Grammar School High School    Name & location of school 
   School   Trade Business Correspondence Grammar School High School College    Name & location of school 

   General Information
   Subjects of special study/research work or special training/skills?
  

   US Military/Naval Service    Rank

  Former Employers (List last four employers, starting with last one first)
 
   1. From: Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec   Year                   To:   Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec    Year 
       Position     Salary  
       Employer name     Employer address 
       Reason for Leaving?  

   2. From: Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec   Year                   To:   Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec    Year 
       Position     Salary  
       Employer name     Employer address 
       Reason for Leaving?  

   3. From: Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec   Year                   To:   Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec    Year 
       Position     Salary  
       Employer name     Employer address 
       Reason for Leaving?  

   4. From: Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec   Year                   To:   Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec    Year 
       Position     Salary  
       Employer name     Employer address 
       Reason for Leaving?  

   References (Names of three persons not related to you who you have known at least one year)
  1.  Name   Address/Phone #   Years Known
  2.  Name   Address/Phone #   Years Known
  3.  Name   Address/Phone #   Years Known

   Authorization
  "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
   I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
   I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative."