Application for Employment
PRE-EMPLOYMENT QUESTIONNAIRE
EQUAL OPPORTUNITY EMPLOYER
Personal Information
DATE
-
Month
-
Day
Year
Date
NAME
First Name
Last Name
Driver's License Front
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of
Driver's License Back
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of
PRESENT ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PERMANENT ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NO.
Format: (000) 000-0000.
SECONDARY PHONE NO.
Format: (000) 000-0000.
REFERRED BY
Employment Desired
POSITION
DATE YOU CAN START
SALARY DESIRED
ARE YOU EMPLOYED NOW?
YES
NO
IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?
YES
NO
EVER APPLIED TO THIS COMPANY BEFORE?
YES
NO
WHERE
WHEN
Education History
Education History
Rows
NAME & LOCATION OF SCHOOL -
YEARS ATTENDED
DID YOU GRADUATE
SUBJECTS STUDIED
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL
General Information
SUBJECT 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)
Former Employers (LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)
Rows
NAME OF EMPLOYER
DURATION
POSITION
REASON FOR LEAVING
1
2
3
4
Back
Next
References (GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.)
Rows
NAME
ADDRESS
BUSINESS
YEARS KNOWN
1
2
3
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 in-formation 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 relevant federal and state laws. I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment." In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to com-plete the required employment eligibility verification document form upon hire.
DATE
-
Month
-
Day
Year
Date
SIGNATURE
This application for employment is sold only for general use throughout the United States. TOPS assumes no responsibility and hereby disclaims any liability for the inclusion in this form of any questions or requests for information upon which a violation of local, state, and/or federal law may be based. It is the user's responsibility to ensure that this form's use complies with applicable laws, which change from time to time.
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