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Application for Employment

(an equal opportunity employer)


PERSONAL INFORMATION

Date__5/23/2017__________________________________________________
Fill in upon employment
Name Jenkins Alexis R
Last First Middle Initial Social Security Number

Present Address 304 East Rd Dimondale Michigan 48821


Street City State Zip

Permanent Address same as above


Street City State Zip

Phone No. ( 630 )487-9327 Height 511 Weight 2


EMPLOYMENT DESIRED
Date 5/23/2017 Salary Range $200,000
Position Pediatrician Available Desired
May We Inquire
Are You Employed Now? no Of Your Present Employer? n/a

Have You Ever Applied to this Company Before? no Where? When?

EDUCATION
Name and Location of School No. of Years Did You Subjects Studied
Attended Graduate?
4 anticipated Math, Science, English, History,
High School __Holt High School, Holt Mi German

College n/a

College _____n/a____________________

Trade, Business or
Correspondence ___n/a_________________
School

Other _____________________________

GENERAL

Subjects of Special Study or Research Work CPR, First Aid and AED certifies

Equipment or Instruments You Can Operate Well Computer, AED

What Foreign Languages Do You Speak fluently? German Read? German Write? German

Military Present Membership in


Service n/a Rank National Guard or Reserves?
(CONTINUED ON OTHER SIDE)
FORMER EMPLOYERS List past employers below, starting with the most recent.

Date Name, Address and Phone of Position Salary Why did you leave?
Month and Year Employer
From_8-16_____ Maurices, 2165 Marketplace Sales $9.15/hour Varsity Tennis season
To 2-17 Blvd Lansing Mi Associate
From___________
To
From___________
To
From___________
To
From___________
To

REFERENCES: Give below the names of three persons not related to you, whom you have known at least one year.
Name Address Occupation Years Acquainted
1 Patrick Kayser 4850 Hummingbird Lane Holt Mi Architect 42

2 Dakota Burk 5983 Dell Road Holt MI Entrepreneur 26

3 Kaiysha Johnson 4927 MLK Blvd Lansing Mi Lawyer 34

PHYSICAL RECORD: Do you have any physical condition which may limit your ability to perform the job applied for?
Explain:
no

In Case of
Emergency Notify Rose Jenkins 304 East Rd (630)4846256
Name Address Phone No.

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of
facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may,
regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.

Date 5-23-17 Signature Alexis Jenkins

DO NOT WRITE BELOW THIS LINE

Interviewed By Date

REMARKS:

Neatness Character
Personality Ability
Hired For Dept. Position Will Report Salary

Approved: 1. 2. 3.
Employment Manager Dept Head General Manager

Adapted with permission for student practice from Form M660-26NR Wilson Jones Company

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