Application for Employment

PRE-EMPLOYMENT QUESTIONAIRE
AN EQUAL OPPORTUNITY EMPLOYER

Personal Information

Which location are you applying for?
Name (Last, First, Middle)
Social Security No.
Must be presented in person
Present Address
Apt. No.
City
State
Zip
Previous Address
Apt. No.
City
State
Zip
Are you 18 Years or Older?
YES NO
Phone
Email

Desired Employment

Position
Date You Can Start
Salary Desired
Are You Employed Now?
YES NO
Is So, May we inquire of your present employer?
YES NO
Have You Ever Applied To This Company Before?
YES NO
Where?
When?
Have You Ever Worked For This Company Before?
YES NO
Where?
When?
Reason for Leaving
Name of the Last Supervisor at this Company
Who Referred You To This Company?
Employment Agency Newspaper Advertising Friend Walk-In State Employment Office College Placement Service Other:

Education

School Level Name and Location of School No. Years Attended Did you Graduate? Subject Studied
Grammar School YES NO
High School YES NO
College YES NO
Trade, Business or Correspondence School YES NO

General

Subjects of Special Study or Research Work
Special Training
Special Skills

Former Employers

List Below Last Three Employers, Starting with the Most Recent

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 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 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

References

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

Name Phone Business Years Acquainted
1.
2.
3.

Service Record

Branch of Service - Please enter N/A if you never served
Discharge Date Rank - Please enter N/A if you never served

Have Ever Been Convicted of a Felony?

YES NO
Explain.

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 OF THIS APPLICATIONS SHALL BE GROUNDS FOR DISMISSAL.

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN ARE 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 FORM UTILIZATIONS 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.”