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Koerner Distributing

Corporate Headquarters

1601 Pike Avenue
Effingham, IL 62401

800.475.5162

info@koernerdistributor.com

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Which Koerner Location are you applying for? *
EffinghamChampaignNew BadenCarterville

Position Name: *

Today's Date: *

First Name: *

Middle Name: *

Last Name: *

Street Address: *

City: *

State: *

Zip: *

Phone Number: *

Email Address: *

Are you 18 years of age or older? *
YesNo

Are you legally eligible for employment in the USA? *
YesNo

Do you have a CDL? *
YesNo

Position Applying For:

Were you recommended to apply?
YesNo

If yes, by whom?

Rate of Pay Expected:

Hours:
Full TimePart Time

Specify days and hours, if part-time:

Ex.: Available Monday through Friday from 8:00 am until 1:30 pm.

Are you willing to work any shift available?
YesNo

Shift Preferences:

Please list your shift preferences and any other information pertinent to your availability.

Are you willing to work additional hours, as necessary?
YesNo

Were you previously employed by us?
YesNo

If yes, when?

If hired, on what date will you be available to start work?

Related Skills, Experiences or Qualifications:

Education

College:

Name and Location of College Attended

Number of Years Attended:

Did you graduate?
YesNo

Comments:

High School:

Name and Location of College Attended

Number of Years Attended:

Did you graduate?
YesNo

Comments:

Past Employment

Most Recent Previous Employer

Past Employment #1: *

Business Location: *

Start Date: *

Separation Date:

Job Duties: *

Name of Supervisor: *

Reason for Leaving:

Past Employment #2:

Business Location:

Start Date:

Separation Date:

Job Duties:

Name of Supervisor:

Reason for Leaving:

Past Employment #3:

Business Location:

Start Date:

Separation Date:

Job Duties:

Name of Supervisor:

Reason for Leaving:

Past Employment #4:

Business Location:

Start Date:

Separation Date:

Job Duties:

Name of Supervisor:

Reason for Leaving:

Military Service

Have you ever served in the US Armed Forces? *
YesNo

If yes, what branch?

Enlistment Date:

Separation Date:

Rank at Discharge:

List of Military Duties and Special Training:

References

Please No Former Employers or Relatives.

Personal Reference: *

City, State: *

Phone Number: *

Personal Reference:

City, State:

Phone Number:

Personal Reference:

City, State:

Phone Number:

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Koerner Distributor Inc.

Corporate Headquarters

1601 Pike Avenue
Effingham, IL 62401

800.475.5162

info@koernerdistributor.com

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