Last Name:    First Name:

Address:

City:   State:    Zipcode:

Home Phone:   Business Phone:   SS#:

Are you at least 18 years of age and under 70 years of age?   Yes   No

If you are under 18 years of age, can you provide a work permit?  Yes   No

Position sought:

Which type of employment are you interested in?  Full-Time   Part-Time   Temporary

When could you start?

Please list any medical limitations which may relate to the work for which you are applying:

Education and Training

High School:

Name and Location of school: 

Years Completed: 1    2    3    4  

Course of Study: 

Ungraduate College/University:

Name and Location of school: 

Years Completed: 1    2    3    4  

Diploma/degree and year conferred: 

Course of Study: 

Graduate/Professional:

Name and Location of school:

Years Completed: 1    2    3    4  

Diploma/degree and year conferred: 

Course of Study: 

Describe any specialized training or education, apprenticeship, volunteer work, skills or extra-curricular activities which you feel are relevant to the job for which you are applying:

Describe any honors or awards you have received that you regard as relevant to the job for which you are applying:

State any additional information you feel may be helpful to us in considering your application for employment:

License and citizenship status

A vehicle is required for some positions.
Do you have access to a car?   Yes    No
Do you have a valid driver's license?   Yes    No
Are you an insured driver?   Yes    No
Are you a United States citizen?   Yes    No
If you are not a United States citizen, do you have an Entry Permit which allows you to work? Yes    No

Work History

List below your recent employment history, beginning with the present or most recent employer.

1. Company Name: 

Address: 

Supervisor's  Name:    Supervisor's  Phone Number: 

Type of Business:    Time Employed:  From (MO/YR) To (MO/YR)

Job Duties:

Starting Salary:   Ending Salary:    Reason for Leaving:

2. Company Name: 

Address: 

Supervisor's  Name:    Supervisor's  Phone Number: 

Type of Business:    Time Employed:  From (MO/YR) To (MO/YR)

Job Duties:

Starting Salary:   Ending Salary:    Reason for Leaving:

3. Company Name: 

Address: 

Supervisor's  Name:    Supervisor's  Phone Number: 

Type of Business:    Time Employed:  From (MO/YR) To (MO/YR)

Job Duties:

Starting Salary:   Ending Salary:    Reason for Leaving:

4. Company Name: 

Address: 

Supervisor's  Name:    Supervisor's  Phone Number: 

Type of Business:    Time Employed:  From (MO/YR) To (MO/YR)

Job Duties:

Starting Salary:   Ending Salary:    Reason for Leaving:

5. Company Name: 

Address: 

Supervisor's  Name:    Supervisor's  Phone Number: 

Type of Business:    Time Employed:  From (MO/YR) To (MO/YR)

Job Duties:

Starting Salary:   Ending Salary:    Reason for Leaving:

References (NOT former employers)

1. Name: 

Address: 

Phone: 

2. Name: 

Address: 

Phone: 

3. Name: 

Address: 

Phone: 

4. Name: 

Address: 

Phone: 

Independent considers applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

I certify the above information is corrected to the best of my knowledge. I authorize Independent Newspapers Inc. to contact all references and employers listed. I also understand I may be required to have a physical examination by a physican at any time requested by the company.

Signature:    Date: