Application For Employment

PRE-EMPLOYMENT QUESTIONNAIRE
EQUAL OPPORTUNITY EMPLOYER

Personal Information
* Last Name
 * First Name
 Middle
* Soc. Sec. No.
 * Driver's License No. & * State
* Email Address
 		* Home Phone Number
( ) - - 		Time at residence
* yrs * mos
* Present Address (Number and Street)
 		* City
 		* County
 		* State
 		* Zip Code

Employment Desired
* Position
 		* Date You Can Start
* Salary Desired
Are You Employed?
Yes No 		If So, May We Inquire Of Your Present Employer?
Yes No
Ever Applied To This Co. Before?
Yes No 		Where?
 		When?

Education History
Name & Location Of School Years
Attended		 Did You
Graduate?		 Subjects Studied
Grammer School Yes No
High School Yes No
College Yes No
Trade, Business Or
Correspondence School 		Yes No

General Information
Subjects Of Special Study/Research Work Or Special Training/Skills
U.S. Military Or Naval Service Rank

Former Employers (List Below Last 4 Employers, Starting With Last One First)
Date
Month & Year		 Name & Address Of Employer Salary Position Reason For Leaving
From:
To:     
From:
To:     
From:
To:     
From:
To:     

REFERENCES (Give Below The Names Of 3 Persons Not Related To You, Whom You Have Known At Least 1 Year)
Name Address Business Years
Known

AUTHORIZATION
"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 to 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 further understand that by submitting this application I acknowledge that I have read and fully understand this authorization."

   
 
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