APPLICATION FOR EMPLOYMENT
PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER
 
Date_______________________________________

PERSONAL INFORMATION
NAME (LAST NAME FIRST)  
                                                                                                             	SOCIAL SECURITY NO.
                                                                                                          	
PRESENT ADDRESS
     	CITY
     	STATE
     	ZIP CODE
     	
PERMANENT ADDRESS
     	CITY
     	STATE
     	ZIP CODE
     	
PHONE NO. 
(                     )     
	REFERRED BY
_J
     	
EMPLOYMENT DESIRED
POSITION
     	DATE YOU CAN START
     	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?
     	
NAME  OF SCHOOL
	LOCATION OF SCHOOL
	YEARS ATTENDED
	DID YOU GRADUATE
	SUBJECTS STUDIED
	
GRAMMAR SCHOOL
     
	     	     	     	     	
HIGH SCHOOL

	

	

	
	
COLLEGE

	

TRADE, BUSINESS OR CORRESPONDENCE SCHOOL

	
	^

GENERAL

 

SUBJECTS OF SPECIAL STUDY/RESEARCH WORK OR SPECIAL TRAINING/SKILLS	

 

RANK
U.S. MILITARY OR NAVAL SERVICE

 

FORMER EMPLOYERS
(LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)
Date
Month & salary                                              Name and address of employer                                   salary                              position                                           reason for leaving
	
FROM

	

TO

	

FROM

	

TO

	

FROM

	

TO

	

FROM

	
	^
	
JO

	

(CONTINUED ON OTHER SIDE)
MAR 1994
C Adams
9661

REFERENCES
GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR
NAME                                                                    ADDRESS                                                      BUSINESS                                  YEARS
	
1

	
	
2      

	
	
3

	
	
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 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."
Date		Signature		
-DO NOT WRITE BELOW THIS LINE-
Remarks	

	

	

	

 

NEATNESS
CHARACTER

 

PERSONALITY
ABILITY

 

HIRED
POSITION
WILL REPORT
SALARY WAGES
FOR DEPT.

 

APPROVED: 1.
.2..
.3..
EMPLOYMENT MANAGER
DEPT. HEAD
GENERAL MANAGER

THIS APPLICATION FOR EMPLOYMENT IS SOLD ONLY FOR GENERAL USE THROUGHOUT THE UNITED STATES. ADAMS ASSUMES NO RESPONSIBILITY AND HEREBY DISCLAIMS ANY LIABILITY FOR THE INCLUSION IN THIS FORM OF ANY QUESTIONS OR REQUESTS FOR INFORMATION UPON WHICH A VIOLATION OF LOCAL, STATE AND/OR FEDERAL LAW MAY BE BASED. IT IS THE USER'S RESPONSIBILITY TO ENSURE THAT THIS FORM'S USE COMPLIES WITH APPLICABLE LAWS, WHICH CHANGE FROM TIME TO TIME.