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Employment Application
Date of Application*
MM slash DD slash YYYY
Position(s) Applied For*
Referral Source*
- Advertisement
- Friend
- Relative
- Walk-In
- Employment Agency
- Other
Last Name*
First Name*
Middle Name*
Phone*
Email*
Skype
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you over 18?*
- Yes
- No
Have you filled out an application here before?*
- Yes
- No
If yes, give date
Have you ever been employed here before?*
- Yes
- No
If yes, give date
Are you employed now?*
- Yes
- No
May we contact your present employer?*
- Yes
- No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?*
- Yes
- No
(Proof of citizenship or immigration status may be required upon employment)
On what date would you be available for work?*
MM slash DD slash YYYY
Are you available to work?*
- Full-time
- Part-time
- Shift work
- Temporary
Are you a lay-off and subject to recall?*
- Yes
- No
Can you travel if your job requires it?*
- Yes
- No
Have you been convicted of a felony in the past 7 years?*
- Yes
- No
(Conviction will not necessarily, disqualify, applicant from employment)
If yes, please explain?*
Veteran of US military service?*
- Yes
- No
If yes, what branch?
Indicate any languages that you speak read or write.
Speak
Fluency
- Fluent
- Good
- Fair
Read
Fluency
- Fluent
- Good
- Fair
Write
Fluency
- Fluent
- Good
- Fair
List professional, trade, business, or civic activities and offices held
(You may exclude those which indicate race, color, religion, sex or national origin)
References
Reference #1*
First Name Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Relationship*
Reference #2*
First Name Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Relationship*
Reference #3*
First Name Last Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Relationship*
Special Employment Notices to Disable Veterans, Vietnam Era Veterans, and Individuals With Physical or Mental Handicaps.

Government contractors are subject to 38 USC 2012 of the veteran era veterans readjustment act of 1974 which requires that they take affirmative action to employ and advance employment qualified disabled veterans and veterans of Vietnam era, and section 503 of the rehabilitation Act of 1973 as amended which requires government contractors to take affirmative action to employ and advance in employment qualified handicapped individuals.

If you are a disable veteran, or have a physical handicap, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodations to enable you to perform the job to the best of your ability in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for employment.
If you wish to be identified, please check box below.
- Handicapped Individual
- Disabled Veteran
- Vietnam Era Veteran
Employment Experience
Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate race, color, religion, sex or national origin.
Employer #1*
Date Employed From*
MM slash DD slash YYYY
Date Employed To*
MM slash DD slash YYYY
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Starting Hourly Rate/Salary*
Ending Hourly Rate/Salary*
Job Title*
Supervisor*
Work Performed*
Employer #2*
Date Employed From*
MM slash DD slash YYYY
Date Employed To*
MM slash DD slash YYYY
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Starting Hourly Rate/Salary*
Ending Hourly Rate/Salary*
Job Title*
Supervisor*
Work Performed*
Employer #3*
Date Employed From*
MM slash DD slash YYYY
Date Employed To*
MM slash DD slash YYYY
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Starting Hourly Rate/Salary*
Ending Hourly Rate/Salary*
Job Title*
Supervisor*
Work Performed*
Employer #4
Dates Employed: From
MM slash DD slash YYYY
Dates Employed: To
MM slash DD slash YYYY
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Starting Hourly Rate/Salary
Ending Hourly Rate/Salary
Job Title
Supervisor
Work Performed
Education
Elementary*
Highest Grade Completed*
High School*
Highest Grade Completed*
Describe course of study:*
Did you receive a diploma?*
- Yes
- No
College/University
Years Completed
Describe course of study:
Did you receive a degree?
- Yes
- No
Describe specialized training, apprenticeship, skills, and extra Curricular Activities
Honors Received
State any additional information you feel may be helpful to us in considering your application.
For Shop Applicants Only
Rate yourself on a scale of 1-10: 1-3 Good, 4-7 Average, 8-10 poor
English Spoken*
Mechanical Ability*
Mathematical Ability*
English Reading*
Working with others*
Blueprint Reading Ability*
English Writing*
Electrical Ability*
Welding Ability*
Do you have experience with computers?*
- Yes
- No
Do you have experience with calculators?*
- Yes
- No
Applicant's Statement
By checking this box you certify that the answers given are true and complete to the best of my knowledge.
By checking this box you authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment.
By checking this box, in the event of employment, you understand that false or misleading information given in your application or interview(s) may result in discharge. You understand also, that you are required to abide by all rules and regulations of the company.
Name
This field is for validation purposes and should be left unchanged.

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Winona Van Norman Inc. of Wichita Kansas is unaffiliated with the now defunct Wisconsin Company that went by the name Winona Van Norman; D & S Manufacturing Inc. or the Winona Van Norman Division, and the Van Norman Group of D & S Manufacturing Inc.