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Application for Employment
Equal Opportunity Employer Pre-Employment Questionnaire
Application Date
*
MM
DD
YYYY
PERSONAL INFORMATION
Name
*
First Name
Last Name
Social Security Number
*
Current Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Secondary
if applicable
(###)
###
####
Email Address
*
EMPLOYMENT DESIRED
Position
*
Date you can start
*
MM
DD
YYYY
Salary Desired
*
Are you employed now?
Yes
No
If so, may we contact your current employer?
Yes
No
Ever applied to this company before?
Yes
No
Where?
When?
EDUCATION HISTORY
High School
Name and Location of School
Years attended
Did you graduate?
Yes
No
Subjects studied
College
Name and Location of School
Years attended
Did you graduate?
Yes
No
Subjects studied
FORMER EMPLOYERS
Please list last three employers beginning with the last employer first.
Employer (most recent)
Name and address of employer
Date, Month and Year of Employment
Salary
Position
Reason for leaving
Employer
Name and address of employer
Date, Month and Year of Employment
Salary
Position
Reason for leaving
Employer
Name and Location of Employer
Date, Month and Year of Employment
Salary
Position
Reason for leaving
REFERENCES
Give below the names of two persons not related to you whom you have known for at least one year.
Name
First Name
Last Name
Contact Number
(###)
###
####
Business
Years known
Name
First Name
Last Name
Contact Number
(###)
###
####
Business
Years known
AUTHORIZATION
I c e r t i f y t h a t t h e f a c t s c o n t a i n e d i n t h i s a p p l i c a t i o n a r e tru e a n d c o m p l e t e t o t h e b e s t o f m y k n o w l e d g e a n d u n d e r s t a n d t h a t , i f e m p l o y e d , f a l s i f i e d s t a t e m e n t s o n t h i s a p p l i c a t i o n s h a l l b e g r o u n d f o r d i s m i s s a l . I a u t h o r i z e i n v e s t i g a t i o n o f a l l s t a t e m e n t s c o n t a i n e d h r e i n a n d t h e r e f e r e n c e s a n d e m p l o y e r s l i st e d a b o v e t o g i v e y o u a n y a n d a l l i n f o r m a t i o n c o n c e r n i n g m y p r e v i o u s e m p l o y m e n t a n d any p e r t i n e n t i n f o r m a t i o n t h e y m a y h a v e , p e r s o n a l o r o t h e r w i s e , a n d r e l e a s e t h e c o m p a n y f r o m a l l l i a b i l i t y f o r a n y d a m a g e t h a t m a y r e s u lt f r o m u t i l i z a t i o n o f s u c h i n f o r m a t i o n . I a l s o u n d e r s t a n d a n d a g r e e t h a t n o r e p r e s e n t a t i v e o f t he c o m p a n y h a s a n y a u t h o r i t y t o e n t e r in t o a n y a g r e e m e n t f o r e m p l o y m e n t f o r a n y s p e c i f i e d p e r i o d o f t i m e , o r t o m a k e a n y a g r e e m e n t c o ntr a r y t o t h e f o r e g o i n g , u n l e s s i t i s i n w r i t i n g a n d s i g n e d b y a n a u t h o r i z e d c o m p a n y r e p r e s e n t a t i v e . T h i s w a i v e r d o e s n o t p e r m i t t h e r e l e a s e o r u s e o f d i s a b l i l y - r e l a t e d o r m e d i c a l i n f o r m a t i o n i n a m a n n e r p r o h i b i t e d b y t h e A m e r i c a n s w i t h D i s a b i l i t i e s A c t ( A D A ) a n d o t h e r r e l e v a n t f e d e r a l a n d stat e l a w s . I u n d e r s t a n d t h a t a c o n s u m e r c r e d i t r e p o r t o r c r i m i n a l r e c o r d s c h e c k m a y b e n e c e s s a r y p r i o r t o m y e m p l o y m e n t . I f s u c h r e p o r t s a r e r e q u i r e d , I u n d e r s t a n d t h a t , i n c o m p l i a n c e w i t h f e d e r a l la w , t h e c o m p a n y w i l l p r o v i d e m e w i t h a w r i t t e n n o t i c e r e g a r d i n g t h e u s e o f t h e s e r e p o r t s a n d w i l l a ls o o b t a i n a s e p a r a t e w r i t t e n a u t h o r i t i o n f r o m m e t o c o n s e n t t o t h e s e r e p o r t s . I a l s o u n d e r s t a n d t h a t a p o o r c r e d i t h i s t o r y o r c o n v i c t i o n w i l l n o t a u t o m a t i c a l l y r e s u l t i n d i s qu a l i f i c a t i o n f r o m e m p l o y m e n t . " I n c o m p l i a n c e w i t h f e d e r a l l a w , a l l p e r s o n s h i r e d w i l l b e r e q u i r e d t o v e r i f y i d e n t i t y a n d e l i g i b i l i t y to w o r k i n t h e U n i t e d S t a t e s a n d t o c o m p l e t e t h e r e q u i r e d e m p l o y m e n t e l i g i b i l i t y v e r i f i c a t i o n doc u m e n t f o r m u p o n h i r e .
Name
*
Signature
*
Typing your name acts as a digital signature and acknowledges authorization.
Thank you!
We will review your application and get back to you as quickly as possible.
