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Application For Employment

Pre-Employment Questionnaire Equal Opportunity Employer


Personal Information
First Name
Last Name
Present Address
 
City
State
Zip Code
Phone Number

Referred By

Employment Desired
Position Date You Can Start
Salary Desired
Are You Employed? If So, May We Inquire of Your Present Employer?
Ever Applied to this Company Before? Yes No Where?
When?
Education History
Name and Location
of School
Years Attended
Did You Graduate?
Subjects Studied
Grammar School
High School
College
Trade, Business or
Correspondence School
General Information

Subjects of Special Study / Research Work or Special Training / Skills

Former Employers

Month, Date, and Year

Name & Address of Employer
Position
Salary
Reason For Leaving

From



To

From



To

From



To

From



To
References

Give Below the Names of Three Persons not Related to You, Whom You Have Known at Least One Year
Address
Business
Years Known
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 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.