Position desired:

Potter Inc. reserves the right to place upon position availability.

Assembly

Bow Maker

Were you referred by a current/ previous employee?

No

Yes

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone

(###)

###

####

Available Start Date:

MM

DD

YYYY

Do you have a High School Diploma/GED?

Yes

No

Hours:

Full Time

Part Time

Time:

Day Shift (Production, 6am to 2:30pm)

Weekends

Status

Regular

Temporary

Are you authorized to work in the U.S on an unrestricted basis?

Yes

No

Have you ever been convicted of a felony?

Convictions will not disqualify an applicant for employment.

No

Yes

Reference #1

First Name

Last Name

Telephone

(###)

###

####

Reference #2

First Name

Last Name

Telephone

(###)

###

####

Reference #3

First Name

Last Name

Telephone

(###)

###

####

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Supervisor's Name:

First Name

Last Name

Telephone

(###)

###

####

May Potter Inc. Contact your Present Employer?

Yes

No

Start Date:

MM

DD

YYYY

End Date:

MM

DD

YYYY

Supervisor's Name:

First Name

Last Name

Telephone

(###)

###

####

Start Date:

MM

DD

YYYY

End Date:

MM

DD

YYYY

Supervisor's Name

First Name

Last Name

Telephone

(###)

###

####

Date

MM

DD

YYYY