Application for Employment
Personalia
Last name		First name
Sex	Male Female
Date of Birth		Place of Birth
Address		Telephone
Nationality		Work permit
Email
Civil Status	Please Select Single Married Living Together Divorced Widow(er)	Name of Partner
Number of Children
Position
Position Desired		Availability Date
Expected Salary
Are there any hours / days you are not available to work?	Yes No
Relatives, Health & History
Names of relatives employed by us		Who referred you to us ?

Have you ever applied here before ?	Yes No
Have you ever been employed by us before ?	Yes No
Do you have any health problems that could influence your job performance ?	Yes No
Are you willing to take a physical exam ?	Yes No
Have you ever had any problems with the police ?	Yes No
PLEASE BE ADVISED THAT A DRUG TEST IS REQUIRED PRIOR TO EMPLOYMENT

Education
	Name/Address of Institution	Graduated
High School
College
Grade School
Courses
LANGUAGES
	Verbal	Written
Dutch	Please Select   Good Reasonable Poor	Please Select   Good Reasonable Poor
English	Please Select   Good Reasonable Poor	Please Select   Good Reasonable Poor
Spanish	Please Select   Good Reasonable Poor	Please Select   Good Reasonable Poor
Papiamento	Please Select   Good Reasonable Poor	Please Select   Good Reasonable Poor

Work History
Note: Begin with present or most recent employer
May we contact your current and previous employer ?	Yes No
Company
Address		Phone
Dates of employment from		To
Your Position		Name Supervisor
Salary at start		At leaving
Why did you leave ?
Company
Address		Phone
Dates of employment from		To
Your Position		Name Supervisor
Salary at start		At leaving
Why did you leave ?
Confirmation code		Please retype code

The information given on this form is true and complete. I authorize investigation of all statements on this application. If I am accepted for employment, I agree to abide to all company rules and regulations. I agree that upon termination of my employment any accounts, which may be owed by me to the company, may be withheld from my final paycheck.