Application

PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER

Date of Application*

Last Name*

First Name*

Middle Name*

Address*

Number*

Street*

City*

State*

Zip Code*

Telephone Number*

Social Security Number

Your E-mail*


EMPLOYMENT DESIRED

Position Applied For*

Date You Can Start*

Desired Wage*

Are You Currently Employed?* YesNo

May We Contact Your Current Employer?* YesNo

Are you 18 Years or Older?* YesNo

Have You Ever Applied With Us Before?* YesNo

When?

What Days Are You Available?* MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Have you been convicted of a felony within the last ten years?*YesNo

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?*YesNo


EDUCATION HISTORY

Name & City/State of School Years Completed Did You Graduate? Course of Study
High School
College/Trade School

GENERAL INFORMATION

Describe Experience With Prior Training or Applicable Skills

U. S. Military or Naval Services

Rank


FORMER EMPLOYERS
(List Below Last Four Employers, Starting With Last One First)
Date: Month & Year
(From - To)
Name & Address Of Employer
Phone No & Contact
Salary Position Reason For Leaving

REFERENCES
(List Below The Names Of Three Persons Not Related To You, Whom You Have Known At Lease One Year)
Name City, State, Phone No. Business Years Known

AUTHORIZATION

“I certify that the facts contained in this application are true and cpmplete 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.”

DATE SIGNATURE