APPLICATION FOR EMPLOYEMENT

PRE – EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER

PERSONAL INFORMATION

First Name ( Last Name First )

Social Security No.

Present Address

City

State

Zip Code

Phone No.

Referred by

EMPLOYMENT DESIRED

Position

Date You Can Start

Are you Employeed 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 of School

Years Attended

Did you graduate?

Subjects Studied

Name of College

Years Attended

Did you graduate?

Subjects Studied

GENERAL INFORMATION

Subject of Special Study/ Research Work.

Special Training

Special Skills

U.S. Military OR Naval Service

Rank

References

GIVE BELOW THE NAME OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.

Name

Address

Business

Years Known

Name

Address

Business

Years Known

Name

Address

Business

Years Known

AUTHORIZATION

I 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. l 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 wIt’s 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 the 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.