APPLICATION FOR EMPLOYMENT-MIDWEST FAMILY BROADCASTING

201 State Street, La Crosse, WI 54601

Applicants are considered for all positions without regard to race, creed, color, ethnic or national origin, religion, sex, age, sexual preference, marital or parenthood status, physical characteristics, veteran status, the presence of a non-job-related medical condition or disability, economic status, or any other legally protected status. If you believe that you have been discriminated against under any of the above laws, you immediately should contact: Midwest Family Broadcasting is an Equal Opportunity Employer. The U.S. Equal Employment Opportunity Commission (EEOC), 1801 L Street, N.W., Washington, D.C. 20507 or an EEOC field office by calling toll free (800) 669-4000. For individuals with hearing impairments, EEOC’s toll free TDD number is (800) 669-6820.

Please Print – Complete Both Sides Date:

Name:
Last First Middle

Address:
Number/Street City State/Zip

Telephone: ( ) Social Security Number:

If necessary, best time to call you at home is:

Are you employed now? Yes No

May we contact your present employer? Yes No

On what date would you be available for work?

Are you interested in working: _____ Full-Time _____Part-Time _____Office _____Engineering

_____Shift Work _____Temporary _____On-Air Station_________

Do you have a valid driver’s license? Yes No If yes, which state?

Do you have proof of auto insurance? Yes No

Place a check to indicate source of referral:

___ Advertisement—Name of publication __________________________________________

___ Employee—Name of employee _______________________________________________

___ Employment Agency Name of employment agency _______________________________

___ Other ____________________________________________________________________

EDUCATION

Circle highest grade completed to date: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Presently attending school at:

Please describe any other training you have received:

EMPLOYMENT EXPERIENCE

List work experience, starting with most recent job.

Summarize special skills and qualifications acquired from employment, school or other experience:

REFERENCES

Give name, address and telephone number of three (3) references who are not related to you and are not previous employers.

Name Address Telephone

APPLICANTS STATEMENT
I certify that the information on this form is true to the best of my knowledge. I understand that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or termination from employment if hired. I give the employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

Signature of Applicant: Date: