APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT QUESTIONAIRE
EQUAL OPPORTUNITY EMPLOYER

PERSONAL INFORMATION DATE:      11/21/2009
NAME: (LAST, FIRST MI) *
SOCIAL SECURITY NO.:


PRESENT ADDRESS: *
CITY: *
 STATE: *
 ZIP CODE: *
PERMANENT ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NO. WITH AREA CODE: *
EMAIL ADDRESS *
REFERRED BY:

EMPLOYMENT DESIRED
POSITION:
DATE YOU CAN START (mm-dd-yyyy):
SALARY DESIRED:
ARE YOU EMPLOYED? 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
NAME & 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:
U.S. MILITARY OR NAVAL SERVICE
 RANK

FORMER EMPLOYERS (List below last four employers, starting with last one first)
DATE
MONTH AND YEAR		 NAME & ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING
FROM
TO
FROM
TO
FROM
TO
FROM
TO
REFERENCES
(Give the names of three persons not related to you, whom you may have known at least one year.)
NAME ADDRESS BUSINESS YEARS
KNOWN

AUTHORIZATION
     "I certify that the fact 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 that 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."
DATE   _______________________ SIGNATURE   ___________________________________________
INTERVIEWED BY   ______________________________________ DATE   _______________________