Application for Employment
Pre-Employment Questionnaire (Equal Opportunity Employer)
Personal Information
Full Name
*
First Name
Middle Initial
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
*
How did you hear about us
Please Select
LinkedIn
Event
Social Media
Company Website
Family / Friend
Other
Phone Number (Secondary)
Referred By
Desired Employment
Desired Position
*
Please Select
Service Technician
Office Worker
Warehouse Worker
Production
Any Position
Desired Start Date
*
-
Month
-
Day
Year
Date
Desired Salary?
Are You Employed Currently?
*
Yes (You May Inquire of My Present Employer)
Yes (I Would Rather Not Share Further)
No
Are You Legally Authorized To Work In The U.S.
*
Yes
No
Have You Applied To This Company In The Past?
Yes
No
If Yes Please Share Details (When, What Position Applied)
Education
Level Of Education
*
High School Degree/Equivalent
College Graduate
Some College
Trade, Business, Or Correspondent School
None
Please Provide Details (Years Attended, Subjects Studied)
General Information
Subject of Special Study/Research Work?
Special Training?
Special Skills?
Military/Naval Service
Rank
Former Employers
(Please Include At Least Two Employers, Starting With The Last One First)
1st Employer (Employer Name & Address, Salary, Position, And Reason For Departure)
*
Worked here from
*
-
Month
-
Day
Year
Date
to
*
-
Month
-
Day
Year
Date
2nd Employer (Employer Name & Address, Salary, Position, And Reason For Departure)
*
Worked here from
*
-
Month
-
Day
Year
Date
to
*
-
Month
-
Day
Year
Date
List For Additional Work History/References (Employer Name & Address, Salary, Position, And Reason For Departure)
*
If you are leaving any additional employer references, please insure to include those employed dates within this box.
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 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 that no representative of the company has any authority to enter into any agreement for employment for any specific 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 waver 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 relevant federal and state laws.
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