Application for Employment

PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER

Personal Information

NAME (LAST NAME FIRST)*
EMAIL ADDRESS*
PRESENT ADDRESS
CITY
STATE
ZIP CODE
PERMANENT ADDRESS
CITY
STATE
ZIP CODE
PHONE NO.
SECONDARY PHONE NO.
REFERRED BY



Employment Desired

POSITION
DATE YOU CAN START
SALARY DESIRED
ARE YOU EMPLOYED NOW? Yes No IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER? Yes No
EVER APPLIED TO THIS COMPANY BEFORE? Yes No WHERE
WHEN



Education History

  NAME & LOCATION YEARS ATTENDED DID YOU GRADUATE SUBJECTS STUDIED
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL



General History

SUBJECT OF SPECIAL STUDY/RESEARCH WORK
SPECIAL TRAINING
SPECIAL SKILLS
U.S. MILITARY OR NAVAL SERVICE
RANK



Former Employers (LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)

DATE (YYYY-MM-DD) NAME & ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING
FROM TO



References (GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR)

NAME ADDRESS BUSINESS YEARS KNOWN



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“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.”

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.