APPLICATION FOR EMPLOYMENT

Pre-Employment Questionnaire • An Equal Opportunity Employer

PERSONAL INFORMATION
Name (As shown on your social security card)
Present Address
Apt. No.
City
State
Zip
Permanent Address
Apt. No.
City
State
Zip
Are you 18 years or older?
     Yes   No
Phone Number
( ) -
Email Address

DESIRED EMPLOYMENT
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?
Ever worked for this company before?
     Yes   No

Where?

When?
Reason for leaving:
Name of last supervisior at this company?:
Who referred you to this company? (Select One)
Employment Agency Newspaper Advertising Friend Walk In
State Employment Office College Placement Service Other:

EDUCATION
School Level Name & Location of School Years
Attended
Did You
Graduate?
Subjects Studied
Grammar School
High School
College
Trade, Business, or Correspondence School

GENERAL
Subject of special study or research work
Special Training
Special Skills

FORMER EMPLOYERS
List below last three employers, starting with the most recent one first
Name of present or last employer
Address
City
State
Zip
Starting Date
Leaving Date
Job Title
Weekly Starting Salary
Weekly Final Salary
May we contact your supervisor? Yes   No
Name of Supervisor
Title
Phone
( ) -
Description of Work
Reason for Leaving

Name of previous employer
Address
City
State
Zip
Starting Date
Leaving Date
Job Title
Weekly Starting Salary
Weekly Final Salary
May we contact your supervisor? Yes   No
Name of Supervisor
Title
Phone
( ) -
Description of Work
Reason for Leaving

Name of previous employer
Address
City
State
Zip
Starting Date
Leaving Date
Job Title
Weekly Starting Salary
Weekly Final Salary
May we contact your supervisor? Yes   No
Name of Supervisor
Title
Phone
( ) -
Description of Work
Reason for Leaving

REFERENCES
Below give the names of three persons you are not related to, whom you have known at lease one year.
Name Address Phone Years Acquainted
1. ( ) -
2. ( ) -
3. ( ) -

SERVICE RECORD
Branch of Service Discharge Date/Rank

Have you been convicted of a felony within the last 5 years? Yes   No
If yes, explain. (Will not necessarily exclude you from consideration)

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 pertintent 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.