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Application for Employment

Pre-Employment Questionnaire/Equal Opportunity Employer

It is our policy to consider applications for all positions without regard to race, color, religion, gender, national origin, age, the presence of a non-job related medical condition or handicap, marital or veteran status, or any other legally protected status.

First Name:
Last Name:
Middle Name:
Address:
City: 
State: 
Zip Code: 
  Township: 
County: 
Phone: 
Email Address:

Are you 18 years of age or older?
Position Applied For:  
Date available to being work:
Are you legally eligible to work in the U.S.?
List friends or relatives working here:

Education
Name & Location of School
Course of Study
Years Completed
Diploma Degree
High
School
Undergraduate
College
Graduate/
Professional

In addition to your work experience, what other skills, qualifications, or other training would be helpful in considering your application:

Work Experience (If resume is attached, falsification of the resume, is grounds for immediate dismissal)
1. Employer
   
Dates Employed
From
To
Address
Telephone Number(s)
Last Pay Rate
   
 
Job Title
Supervisor
Reason for Leaving
Work Responsibilities
We may contact this employer unless you indicate a reason here:
2. Employer
   
Dates Employed
From
To
Address
Telephone Number(s)
Last Pay Rate
   
 
Job Title
Supervisor
Reason for Leaving
Work Responsibilities
We may contact this employer unless you indicate a reason here:
3. Employer
   
Dates Employed
From
To
Address
Telephone Number(s)
Last Pay Rate
   
 
Job Title
Supervisor
Reason for Leaving
Work Responsibilities
We may contact this employer unless you indicate a reason here:

References
Give the names of three persons not related to you, whom you have known at least one year.
1. Name
Relationship
Address
Phone #
Yrs. Acquainted
2. Name
Relationship
Address
Phone #
Yrs. Acquainted
3. Name
Relationship
Address
Phone #
Yrs. Acquainted

I understand that the facts contained in this application are true and complete to the best of my knowledge and understand this if employed, falsified statements on thsi application may be grounds for dismissal

I authorize investigation of all statements mentioned herein and the references and employers listed above to give you any and all information concerning my employment and any pertinent information that may have, personal or otherwise and release said company from all liability for any damage that may result from utilization of such information.

This waiver does not permit the release of any medical information in a manner prohibited by the American with Disabilities Act, HIPPA and other federal and/or state laws.



Name of Applicant   

By submitting this form, I certify that I have read, fully understand and accept all terms of foregoing Applicant Statement.

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