Application for Employment

Department of Human Resources
1420 South 700 West SLC, UT 84104
Phone (801) 972-1009 / Fax (801) 972-9337
Web Address:
Check all that you may be interested in:     Full Time       Part Time
Last Name: First Name: Middle Initial:
Mailing Address: City:
State: Zip: Cell Phone: Home Phone: Business Phone : E-Mail Address:
Driverís License #: State: Expiration Date: Operators (Private Vehicle) CDL License Class : Endorsement : Endorsement :
Are you claiming Veteranís Preference? (Attach a copy of DD214 and/or service connected disability): Yes NO
Have you ever been convicted of a felony? If yes, please complete the following: (Conviction is not an automatic bar to employment. Each case is considered on its individual merits).
Nature of Offense                                     Name & Location of Court                                                                                 Date of Conviction
(Inaccurate information here will result in disqualification.)
Yes NO
Have you ever been discharged or forced to resign from any position? If yes, please give employer, date and reason.
Employer                                                          Date                      Reason
Yes NO
Do you have any relatives working for Victorís Tires, Victorís Restaurant, or Victorís Auto? If yes, please complete the following:
(Continue listing relatives on a separate page if necessary)
Name                                                                                   Relationship                                              Department                
Yes NO
If hired, are you authorized to work in the United States? For non citizens, a copy of your authorization to work
issued by the U.S. Immigration and Naturalization Service must be submitted prior to appointment
Yes NO
Do you have any physical conditions that could limit your work? If yes, please list conditions and limitations.
Yes NO
Do you have any previous back injuries? If yes, please specify injury and state when it occurred.
Yes NO
What days can you work? Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Name Reference Telephone Number Reference