Please provide the following contact information:

Name

Date of Birth

Address

Apt#

City

State

Zip

Day Time Phone Number 

(include area code)

CHECK BOX IF OK TO CALL 

Please indicate if this is home or business:    

HOME BUSINESS If yes, when:

Evening Phone Number 

(include area code) 

CHECK BOX IF OK TO CALL 

Please indicate if this is home or business:   

HOME BUSINESS If yes, when:

Email address

Please answer the following questionnaire:

Have you ever applied with Rieker before?

YES NO Please Select from List

How did you hear about Rieker?

What made you apply with Rieker?

Are you a citizen of the United States? 

If you answered no, please provide your alien registration number here:

Have you been convicted of a crime? 

If you answered yes, please provide what you were convicted of and when:

Have you ever had a drug or alcohol related problem? 

If you answered yes, please provide what it was and when:

Have you ever been convicted of physically assaulting or harassing anyone? 

If you answered yes, please provide what it was and when:

Please indicate your means of transportation to work: 

How many times in the past year has your transportation caused you to be late for work?

Education

High School Attended:

Years attended:

  0 1 2 3 4 5 5 +

Level attained:

COMPLETED GED GRADUATED DID NOT GRADUATE Please Select from List

What did you study:

College Attended:

Years attended:

0 1 2 3 4 5 6 6+

Level attained:

DID NOT ATTEND DID NOT GRADUATE GRADUATED Please Select from List

Degree Received:

Trade or Business School Attended:

Years attended:

0 1 2 3 4 5 6 6+

Level attained:

DID NOT ATTEND DID NOT GRADUATE GRADUATED Please Select from List

Degree/Certificate Received:

Any additional subjects of special study, research work, hobbies, interests?

Have you ever served in any branch of the US military?

Which Branch? ARMY NAVY MARINES AIR FORCE COAST GUARD NATIONAL GUARD DID NOT SERVE

Are you presently a member of the National Guard or Military Reserve?

Which Branch? ARMY RSVS NAVY RSVS MARINES RSVS AIR FORCE RSVS COAST GUARD NATIONAL GUARD NOT A MEMBER

Employment Status

Are you currently employed?

How long:

Company Name:

Position Held:

YES NO Please Select from List

If yes, best time:

Employer Contact Person:

Employer Contact Phone:

If you are hired, how much time will you require to give notice to your present employer?

Employment History and References

Previous Employer 1:

Company Name:

Position Held:

How long:

Address:

Reason for leaving:

Employer Contact Person:

Employer Contact Phone:

Previous Employer 2:

Company Name:

Position Held:

How long:

Address:

Reason for leaving:

Employer Contact Person:

Employer Contact Phone:

Personal References

Reference 1:

Reference Name:

Relationship to Reference:

Reference Phone:

How long have you known this person: 

Reference 2:

Reference Name:

Relationship to Reference:

Reference Phone:

How long have you known this person: 

Reference 3:

Reference Name:

Relationship to Reference:

Reference Phone:

How long have you known this person: