APPLICATION FOR EMPLOYMENT/Pre-Employment Questionnaire (Equal Opportunity Employer)

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

POSITION/JOB DESIRED: *

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DATE YOU CAN START: *

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WAGE DESIRED:

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Are you currently employed? *

If yes, may we inquire of your present employer?

Name of Present or Last Employer/Supervisor & Company Name:

What was your position & what was your wage?

FORMER EMPLOYERS

	Last/Current Employer
Company Name:	Last/Current Employer
Supervisor Name:	Last/Current Employer
Supervisor Phone #:	Last/Current Employer
Position/Description of work:	Last/Current Employer
Starting date & ending date:	Last/Current Employer
Reason for Leaving:	Last/Current Employer
May we contact your supervisor?	Last/Current Employer

Former Employers Continued

	Previous Employer
Company Name:	Previous Employer
Supervisor Name:	Previous Employer
Supervisor Phone #:	Previous Employer
Position/Description of work:	Previous Employer
Starting date & ending date:	Previous Employer
Reason for Leaving:	Previous Employer
May we contact your supervisor?	Previous Employer

Former Employers Continued

	Previous Employer
Company Name:	Previous Employer
Address:	Previous Employer
Supervisor Name:	Previous Employer
Supervisor Phone #:	Previous Employer
Position/Description of work:	Previous Employer
Starting wage:	Previous Employer
Final wage:	Previous Employer
Starting date:	Previous Employer
Ending date:	Previous Employer
Reason for Leaving:	Previous Employer
May we contact your supervisor?	Previous Employer

EDUCATION HISTORY

	Name	Years attended	Did you graduate?	Subjects studied
High School	Name	Years attended	Did you graduate?	Subjects studied
College	Name	Years attended	Did you graduate?	Subjects studied
Trade, Business, or Other	Name	Years attended	Did you graduate?	Subjects studied

SPECIAL SKILLS

	List any that may be useful to your employment
Special Training	List any that may be useful to your employment
Special Qualifications/Licenses/Certifications	List any that may be useful to your employment
Special Studies/Accomplishments	List any that may be useful to your employment

MILITARY SERVICE

	Please answer the following:
Have you ever served in the U.S. Armed Forces?	Please answer the following:
Branch of Service:	Please answer the following:
Rank:	Please answer the following:
Discharge Date/Active/Reserve	Please answer the following:

REFERENCES (List Professional References whom we may contact)

	Name	Business	Phone or Email
Reference 1	Name	Business	Phone or Email
Reference 2	Name	Business	Phone or Email
Reference 3	Name	Business	Phone or Email

The following information will not be used to discriminate against the applicant during the hiring process for any reasons relating to race, color, sex, religious affiliation, national origin, gender, or any disability. Questions regarding physical abilities are used under the American with Disabilities Act and will not be used to discriminate against the applicant during the hiring process for any reasons relating to disabilities, health problems, or medical conditions. *

	NO	YES
Have you been convicted of a felony within the last 5 years? (If record was expunged, sealed or set aside, you may answer no)	NO	YES
If necessary, I will sign consent for a criminal background check.	NO	YES
I have a valid drivers' license and am an insured motorist.	NO	YES
I am able to lift and or carry, push, or pull at least 50 lbs.	NO	YES
I may require special accommodation(s) to perform my job.	NO	YES

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 alll 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.

I understand that a criminal records check may be necessary prior to my employment and if 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 conviction will not automatically result in disqualification from employment."

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.

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Your name here will constitute your signature on this application for employement. *

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