Application For Employment

(Pre-Employment Questionnaire)      (An Equal Opportunity Employer)

Personal Information

Name: Date:
Last First Middle SSN:
Present Address:
Street City State ZIP
Permanent Address:
Street City State ZIP
Phone Number: Are you 18 years or older?
E-Mail Address:

Are you either a U.S. citizen or an alien authorized to work in the United States?

Employment Desired

Position: Date you can start: Salary desired:
Are you employed now? If so, may we inquire of your present employer?
Ever applied to this company before? Where? When?
Referred by:
Education Name & Location of School *Number of Years Attended *Graduated Subjects Studied
Grammar School



High School



College



Trade, Business or Correspondence School



General

Subjects of special study or research work:



Special skills:


Activities (Civic, Athletic, etc.):
Exclude organizations, the name of which indicates the race, creed, sex, age, marital status, color or nation of origin of its members.
U.S. Military or Naval Service: Rank: Present Membership in National Guard or Reserves:

Former Employers (List below at least three employers, starting with last one first.)

Date
Month & Year 		Name & Address of Employer Salary Position Reason for Leaving
From:



To:
From:



To:
From:



To:
Which of these jobs did you like best?


What did you like most about this job?

References Give the names of three persons, not related to you, whom you have known at least one year.

Name Address Business Phone Number Years Acquainted
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, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice and without cause."