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:

Township:

County:

Phone:

Email Address:

Are you 18 years of age or older?

YesNo

Position Applied For:

Date available to being work:

Are you legally eligible to work in the U.S.?

YesNo

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.