Application for Employment

Pre-employment Questionnaire. Equal Opportunity employer. This form is encrypted to insure that this information is secure. Your information will never be sold or given away.

Employment Desired  
Position?
Position Type? Full time Part time Seasonal
Available Start Date?
Salary Desired?
Yes No
If so, may we inquire of your present employer?
Yes No
Personal Information  
Full Name
(Last, Middle, First)
Have you ever worked for this company? Yes No
Have you ever been convicted of a felony? Yes No
Authorized to work in the US? Yes No
Referred By
Email Address
Phone Number
Address
City
Postal Code
Education History  
  High School
Name
Location
Years Attended
Did you Graduate Yes No
   
  College
Name
Location
Years Attended
Did you Graduate Yes No
Subject Studied
   
  Trade, Business, or Correspondence School
Name
Location
Years Attended
Did you Graduate Yes No
Subject Studied
Former Employers List below last four employers, starting with last one first.
  Employer 1
Company Name
Date Employed From:   To:
Address
Salary
Position
Responsibilities
Reason for Leaving
   
  Employer 2
Company Name
Date Employed From:   To:
Address
Salary
Position
Responsibilities
Reason for Leaving
   
  Employer 3
Company Name
Date Employed From:   To:
Address
Salary
Position
Responsibilities
Reason for Leaving
Military Service  
Branch
  From:   To:
Rank at Discharge
Type of Discharge
If other than honorable, explain
References Please list three professional references.
  Reference 1
Full Name
Relationship
Business
Phone
Address
   
  Reference 2
Full Name
Relationship
Business
Phone
Address
 
  Reference 3
Full Name
Relationship
Business
Phone
Address

Authorization

By submitting your application, you agree to these terms "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 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.
I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are 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 poor credit history or conviction will not automatically result in disqualification from employment.”

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 from upon hire.