Submit resumes to: Human Resources, P.O. Box 13153, Dayton, OH 45413
or email Microsoft Word compatible document to apply@screenworksinc.com

Personal Information:

First Name
Last Name
Social Security No.
Address
City, State Zip
Phone Number
Email Address
Are you 18 years or older?	Yes No

Desired Employment:

Name and location of school
Number of years attended
Did you graduate?	Yes No
Subjects Studied

College

Name and location of school
Number of years attended
Did you graduate?	Yes No
Subjects Studied

Trade, Business, or Correspondence School

Name and location of school
Number of years attended
Did you graduate?	Yes No
Subjects Studied

General:

Subjects of special study or research
Special Training
Special Skills

Former Employers:
List below you last three employers, starting with the most recent one first.

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Name of employer
Address
City, State Zip
Starting Date
Leaving Date
Job Title
Weekly starting salary
Weekly final salary
May we contact your supervisor?	Yes No
Name of supervisor
Title
Phone number
Description of work
Reason for leaving

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Name of employer
Address
City, State Zip
Starting Date
Leaving Date
Job Title
Weekly starting salary
Weekly final salary
May we contact your supervisor?	Yes No
Name of supervisor
Title
Phone number
Description of work
Reason for leaving

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Name of employer
Address
City, State Zip
Starting Date
Leaving Date
Job Title
Weekly starting salary
Weekly final salary
May we contact your supervisor?	Yes No
Name of supervisor
Title
Phone number
Description of work
Reason for leaving

References:
Below, give the names of three persons you are not related to, whom you have known at least one year.

Name	Address / Phone	Business	Years Acquainted

Service Record:

Branch of Service	Discharge Date	Rank

Have you been convicted of a felony within the last 5 years? Yes No

If yes, explain: (Will not necessarily exclude your from consideration)

Comments/Questions:

By clicking the apply button below, you agree to the following statement:

"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 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."

Copyright ©2003 Screen Works, Inc.