APPLICATION FOR EMPLOYMENT
PRE-EMPLOYMENT QUESTIONNAIRE
EQUAL OPPORTUNITY EMPLOYER    
PERSONAL INFORMATION
DATE:
NAME:(LAST NAME FIRST)
SOCIAL SECURITY NO.
- -
PRESENT ADDRESS
City
State
Zip
PERMANENT ADDRESS
City
State
Zip
Phone
Email
REFERRED BY
EMPLOYMENT DESIRED
POSITION:
DATE YOU CAN START
SALARY DESIRED:

       
ARE YOU
EMPLOYED NOW?
IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?
ARE YOU LEGALLY AUTHORIZED TO WORK IN THE US?
EVER APPLIED TO
THIS COMPANY BEFORE?
WHERE?
WHEN?
EDUCATION HISTORY
HIGH SCHOOL NAME & LOCATION OF SCHOOL YEAR
ATTENDED		 DID YOU
GRADUATE? 		SUBJECTS STUDIED
HIGH SCHOOL
COLLEGE
TRADE,BUSSINESS OR
CORRESPONDENCE
SCHOOL
GENERAL INFORMATION
SUBJECTS OF SPECIAL
STUDY/RESEARCH WORK
SPECIAL TRAINING
SPECIAL SKILLS
U.S. MILITARY OR
NAVAL SERVICE
RANK
FORMER EMPLOYERS   (LIST BELOW LAST FOUR EMPLOYERS,STARTING WITH LAST ONE FIRST)
DATE
MONTH AND YEAR		 NAME & ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING
From:
To:
From:
To:
From:
To:
From:
To:
REFERENCES   GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.
NAME ADDRESS BUSSINESS YEARS KNOWN
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 disminssal.
   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.
   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.
  This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relvevant federal and state laws."