Now Hiring PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER PERSONAL INFORMATIONName (Last Name, First Name) *Present Address *City *State *ZIP Code *Permanent AddressCityStateZIP CodePhone *Referred ByEMPLOYMENT DESIREDPositionSalary RequestedDate you can startAre you employed?YesNoIf so, may we inquire of your present employer?YesNoEver applied to this company before?YesNoIf Yes:Where?When?EDUCATION HISTORYGrammar SchoolName & Location of SchoolYears AttentedDid You Graduate?Subjects StudiedHigh SchoolName & Location of SchoolYears AttentedDid You Graduate?Subjects StudiedCollegeName & Location of SchoolYears AttentedDid You Graduate?Subjects StudiedYears AttentedTrade, Business Or Correspondence SchoolName & Location of SchoolYears AttentedDid You Graduate?Subjects StudiedGeneral InformationSubjects of special Study/Research Work or Special Training/SkillsU.S. Military Or Naval ServiceRankFORMER EMPLOYERS ((List below last four employers, starting with last one first)Date (From)Date (To)Name & Address of EmployerPositionReason for LeavingDate (From)Date (To)Name & Address of EmployerPositionReason for LeavingDate (From)Date (To)Name & Address of EmployerPositionReason for LeavingDate (From)Date (To)Name & Address of EmployerPositionREFERENCES (Give below the names of three persons not related to you, whom you have known at least one year)NameAddressBusinessYears KnownNameAddressBusinessYears KnownNameAddressBusinessYears KnownAUTHORIZATION "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 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 qriting 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" DateSignature SubmitPlease do not fill in this field.
