Personal Data Sheet

Contact Information
First name       Last name      Middle I.

Street     City     State     Zip Code

Phone Number. (  )-

Personal Information
* Birthdate (mm-dd-yy)    - -

* Social Security Number - -

* Height    *Weight        * Sex M    F

* Color of eyes     *Color of hair

Person to notify in case of emergency (Name and phone#):

* Disability:

* Physician's Name
Address Phone -

* Activities and Hobbies:
1.
2.
3.

* Health Concerns:

* Medications taken:

Employment Information
Are you currently employed? Yes No

May we contact your present employer? Yes No

Are you legally entitled to work in the United States? Yes No

Shifts that you are willing or able to work
Days
Swing
Nights
Weekends
Graveyard

Work Preference
Full time
Part time
Temporary

Have you been convicted of a felony within the last seven years? Yes No
If yes, please indicate the date and nature of the offense

Parent/Guardian
Address
Phone -