APPLICATION FOR EMPLOYMENT

(PRE-EMPLOYMENT QUESTIONNAIRE)

(AN EQUAL OPPORTUNITY EMPLOYER)

Date:

PERSONAL INFORMATION

Name Last:   First:   Middle:

Email:

Present Address Street:

City:   State:   Zip:

Permanent Address Street:

City :   State:   Zip:

Phone Number:   Home  Cell

Are You 18 Years or Older? Yes  No

Special Questions

Are you legally authorized to work in the U.S.? Yes  No
Proof of identity and eligibility will be required upon hire.

What Foreign Languages do you speak fluently?

Read?

Write?

Have you been convicted of a felony or misdemeanor within the last 5 years?
** Yes  No

Describe:

I understand and agree that I may be required to take one or more: Physical examination; Drug screen, as a condition of hiring or continued employment. I agree to consent to take such test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising in connection with the use of such tests. Yes  No

**You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.

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

GRAMMAR SCHOOL

Name and Location
of School		 *No of Years
Attended		 *Did You
Graduate?		 Subjects Studied

HIGH SCHOOL

Name and Location
of School		 *No of Years
Attended		 *Did You
Graduate?		 Subjects Studied

COLLEGE

Name and Location
of School		 *No of Years
Attended		 *Did You
Graduate?		 Subjects Studied

TRADE, BUSINESS OR CORRESPONDENCE SCHOOL

Name and Location
of School		 *No of Years
Attended		 *Did You
Graduate?		 Subjects Studied

*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

GENERAL

Subjects of Special Study or Research Work

U.S. Military or Naval Service

Rank

Present Membership in National Guard or Reserves

FORMER EMPLOYERS

(List Below Last Three Employers, Starting With The Last One First).

Name of Employer

Address of Employer

Phone Number:

Salary    Position 

Reason for Leaving

From    To 

Name of Employer

Address of Employer

Phone Number:

Salary    Position 

Reason for Leaving

From    To 

Name of Employer

Address of Employer

Phone Number:

Salary    Position 

Reason for Leaving

From    To 

REFERENCES:

Give the Names of Three Persons not Related to You, Whom You Have Known at Least One Year.

Name    Address 

Phone:

Business    Years Acquainted 

Name    Address 

Phone:

Business    Years Acquainted 

Name    Address 

Phone:

Business    Years Acquainted 

Can you Perform the Essential Functions of Your Job, With or Without a Reasonable Accommodation?  Yes     No 

Please Describe 

In Case of Emergency Notify

Name 

Address 

Phone Number 

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 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 all parties from all liability for any damage that may result from furnishing same to you.

If hired, I understand that my employment is at-will and can be terminated at any time, with or without notice, for any reason at the option of the company or me. Should the company hire me, I agree to observe all the company’s policies, practices and procedures currently in existence and new or revised ones, which may be issued in the future.

Date

Signature