POSITION DESIRED:

(PRE-EMPLOYMENT QUESTIONNAIRE) AN EQUAL OPPORTUNITY EMPLOYER

Applicants are considered without regard to race, color, religion, sex/gender, national origin, age, marital, veteran status, or the presence of a non-job-related medical condition or handicap.
Date

MonthDayYear
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
POSITION DESIRED:

Administrative Assistant
Date you can start:

MonthDayYear
Referred by:
Are you currently employed?

YesNo
If yes, may we inquire of your present employer?

YesNo
Have you ever applied to NCCOA/NTS before?

YesNo
If yes, when?
Please provide date of last application, to the best of your recollection.
Have you ever been discharged or asked to resign from a job?

YesNo
If yes, from which business/organization?
EMERGENCY CONTACT NAME:

First NameLast Name
EMERGENCY CONTACT PHONE:
Please enter a valid phone number.
Have you ever tested positive, or refused a test on any pre-employment drug and alcohol test required/administered by an employer ?

YesNo
EMPLOYMENT/WORK EXPERIENCE:

Begin with current or most recent position. Include military service and volunteer activities
PERSONAL REFERENCES:

Please provide the name, address, phone number, and email of three individuals not related to you.
Reference #1
Reference #2
Reference #3
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 to give you any and all information concerning my previous employment and any pertinent information they may have personal or otherwise, 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 date or date of payment of my wages and salary, be terminated at any time without any prior notice.

I understand also, that I am required to abide by all rules, regulations and policies of the Noble County Council On Aging/Noble Transit Service.
Date

MonthDayYear
Signature

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