Application for Employment
Pre-employment questionnaire
Equal Opportunity Employer PERSONAL INFORMATION *Last Name: *First Name: Social Security Number: Referred by: Address: City: State: Zip: *Phone Number: Position: Available Start Date: Salary Desired: Are you employed: Yes No May we contact: Yes No Applied before: Yes No When: EDUCATION HISTORY Education Type: HS College Trade School Dates Attended: Name and Location of School Education Type: HS College Trade School Dates Attended: Name and Location of School GENERAL INFORMATION General Information: (Special study or work training Prior / Current Military: Yes No Branch: Rank: Honorable Discharge: FORMER EMPLOYERS List below last four (4) employers, starting with the last one first. * Employer Name: Position: Employer Address: Salary: Start Date: End Date: Reason for Leaving: Employer Name: Position: Employer Address: Salary: Start Date: End Date: Reason for Leaving: Employer Name: Position: Employer Address: Salary: Start Date: End Date: Reason for Leaving: Employer Name: Position: Employer Address: Salary: Start Date: End Date: Reason for Leaving: REFERENCES List the names of three (3) persons not related to you, whom you have known for at least one year. * Reference: # of years known: Reference Complete Address: * Reference: # of years known: Reference Complete Address: * Reference: # of years known: Reference Complete Address: "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 statement 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 an and all information concerning my pervious 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." By checking this box, I signifying that the information is true and accurate:
PERSONAL INFORMATION
EDUCATION HISTORY
Dates Attended:
GENERAL INFORMATION
FORMER EMPLOYERS List below last four (4) employers, starting with the last one first.
Position:
Start Date:
End Date:
REFERENCES List the names of three (3) persons not related to you, whom you have known for at least one year.
# of years known:
"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 statement 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 an and all information concerning my pervious 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."
