Application for Employment Pre-Employment Questionnaire Equal Opportunity Employer Personal Information Last Name* First Name* Middle Initial* Present Address* City* State* Zip Code* Permanent Address* City* State* Zip Code* Email Address* Primary Phone* Secondary Phone* Employment Desired Position Date You Can Start Salary Desired Are You Currently Employed? YesNo If So, May We Contact Your Present Employer? YesNo Have You Applied to This Company Before? YesNo Where When Education History High School Graduate or Equivalent? YesNo Name of High school High school Address High school City High school State High school Zip High School - Date Attended From High School - Date Attended To Did you attend college or trade school? YesNo College or Trade School - Date Attended From College or Trade School - Date Attended To Type of degree/certification earned General Information Special Training Special Skills Have you ever served in the Armed Forces? YesNo If so, what branch? ArmyNavyAir Force Rank Employment History Most Recent Employer Most Recent Employer - Date From Most Recent Employer - Date To Employer Employer Address, City, and State Most Recent Wages Job Title and Description Reason for Leaving Second Most Recent Employer Second Most Recent Employer - Date From Second Most Recent Employer - Date To Employer Employer Address, City, and State Most Recent Wages Job Title and Description Reason for Leaving Third Most Recent Employer Third Most Recent Employer - Date From Third Most Recent Employer - Date To Employer Employer Address, City, and State Most Recent Wages Job Title and Description Reason for Leaving Which of these jobs did you like best and why? Personal References Reference 1 Name Address Occupation Phone Reference 2 Name Address Occupation Phone Reference 3 Name Address Occupation Phone 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. 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 Stales and to complete the required employment eligibility verification document form upon hire.