Last Name:          First Name:      Middle Initial: 

Address Line 1 : 

Address Line 2:     

City:          State:        Zip:  

Position(s) applied for: 

How did you learn of the position? 

Have you previously been employed by R.L. Lewis Industries, Inc.?  YES NO     If yes, when? 

Are you at least 18 years of age?  YES NO

Are you a U.S. citizen or an alien legally authorized to work in the U.S.?  YES NO

On what basis are you available for employment?  Full Time Part Time Summer Temporary

Are you available for:    Weekends and Holidays?   YES NO

                                   Rotating Shifts?  YES NO

                                   On Call?   YES NO   

Shift Preference:  1st 2nd 3rd Any

Date available for work:                       Rate of pay expected:  per hour.