Application for Employment

Pre-Employment Questionnaire
An Equal Opportunity Employer

Personal Information
Last Name: First Name:
Street Address:
City:  State:  Zip:  Years at Address:
Home Phone: Cellular Phone:
EMail Address:
Are you 18 years of age or older?  
   
Desired Employment
Position: Start Date:
Salary Desired:   Hourly  Weekly Yearly  
Are you Employed now? Yes No May we contact them? Yes No
Have you worked here before? Yes No If so, when?
Reason for leaving?
How did you hear about us?
   
Education
School Level Name and Location of School No of Years Attended Subjects Studied
High School
College
Trade School
Other
   
General
Subjects 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 Most Recent Employer

Address

City State Zip

Starting Date Leaving Date
  Job Title
Starting Salary Ending Salary May we contact them? Yes No
Supervisor Supervisor's Title Supervisor's Phone
Description of Work
Reason for Leaving

 

Previous Employer

Address

City State Zip

Starting Date Leaving Date
  Job Title
Starting Salary Ending Salary May we contact them? Yes No
Supervisor Supervisor's Title Supervisor's Phone
Description of Work
Reason for Leaving

 

Previous Employer

Address

City State Zip

Starting Date Leaving Date
  Job Title
Starting Salary Ending Salary May we contact them? Yes No
Supervisor Supervisor's Title Supervisor's Phone
Description of Work
Reason for Leaving

 

 

References
Below, give the names of three persons you're not related to, whom you have known at least one year.
  Name Phone Number Business Years Acquainted
1
2
3
Service Record
Please describe your service record below.  Be sure to include dates, branches, and ranks.
Other Background
Have you been convicted of a felony within the last 5 years? Yes No
If yes, please 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 ground for dismissal.

I authorize investigation of all statements contained herein and the referenced and employers listed above to give you any and all information concerning my previous employment and 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 specified period of time, or to make any agreement contract to the foregoing, unless it is in writing and signed by an authorized company representative.

By submitting this application, I agree to the above terms and conditions