Application For Employment

PRE-EMPLOYMENT QUESTIONNAIRE

EQUAL OPPORTUNITY EMPLOYER


Personal Information


NAME (LAST NAME, FIRST NAME MI)

DATE

PRESENT ADDRESS

CITY

STATE

ZIP

PERMANENT ADDRESS

CITY

STATE

ZIP

PHONE NO.
()

OTHER NAMES USED: (I.E., MAIDEN NAME, AKAs)

REFERRED BY:


Employment Desired

POSITION

F/T
   P/T

DATE YOU CAN START

SALARY DESIRED

ARE YOU PRESENTLY EMPLOYED? YES   NO

IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?
YES NO

HAVE YOU EVER APPLIED TOWORK FOR THIS COMPANY BEFORE?
YES NO

 WHEN
 EXPLAIN

Education History

NAME & LOCATION OF SCHOOL

GRADUATED
Yes/No

SUBJECTS STUDIED


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

ARE YOU WILLING TO WORK OVERTIME? YES NO

ARE YOU AT LEAST 18 YEARS OLD? YES NO

IF NOT, CAN YOU PROVIDE A VALID WORK PERMIT, HIGH SCHOOL DIPLOMA, OR EQUIVALENT? YES NO

WHAT LANGUAGES DO YOU SPEAK, READ, OR WRITE FLUENTLY?

SPEAK:

READ:

WRITE:

DO YOU HAVE A RELIABLE MEANS OF TRANSPORTATION TO GET TO WORK? YES NO

ARE THERE ANY TIMES DURING THE WEEK THAT YOU ARE NOT AVAILABLE TO WORK? YES NO

IF SO, PLEASE EXPLAIN:

CAN YOU WORK ALL HOLIDAYS? YES NO

DO ANY OF YOUR RELATIVES WORK FOR THIS COMPANY? YES NO

IF SO, WHO?

HAVE YOU EVER BEEN CONVICTED OF A CRIME, EXCLUDING MISDEMEANORS AND SUMMARY OFFENSES? YES NO

(Note: conviction will not necessarily disqualify applicant)

IF SO, PLEASE EXPLAIN:

HOW DID YOU FIND OUT ABOUT THIS JOB?


Former Employers (LIST BELOW LAST TEN YEARS OF EMPLOYMENT, STARTING WITH THE MOST RECENT)

DATE

MONTH AND YEAR

NAME & ADDRESS OF EMPLOYER

SALARY

POSITION

REASON FOR LEAVING

FROM

START PAY



TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID



FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID

 

FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID

 

FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID



FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID



FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID



FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID



FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID



FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID



FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID



FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID



FROM

NAME & ADDRESS OF EMPLOYER

START PAY

POSITION

REASON FOR LEAVING

TO

SUPERVISOR

MAY WE CONTACT
YES NO

PHONE

LAST PAY

DESCRIBE THE WORK YOU DID

 

References (GIVE BELOW THREE NAMES OF PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.)

NAME

ADDRESS

BUSINESS

PHONE

YEARS KNOWN
















 

Certification and Acknowledgement

  I certify that the information provided herein is true and correct to the best of my knowledge. I understand that, if employed, falsified statements on this Application for Employment form will be considered grounds for termination.

I authorize the company to thoroughly investigate my work experience and any other matters related to my suitability for employment. I further authorize my former employers to disclose to the company any and all information they may have concerning my previous employment. In addition, I hereby release the company, my former employers, and all other persons from any and all claims, demands, or liabilities arising out of, or in any way related to, such disclosure.

I acknowledge that, if employed, both the company and I have the right to terminate the employment relationship at any time, with or without cause or advance notice. This employment at-will relationship will remain in effect throughout my employment with the company and may not be modified by any oral or implied agreement.

I also understand and agree that no representative of the company has 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.

 

Signatures