Pre-Employment Questionnaire (An Equal Employment Opportunity Employer)
 
NAME / Last / First / MI.
E-mail
Present Address
Street
City
State
ZIP
Permanent Address
Street
City
State
ZIP
Phone Number
Home
Work/Other
SHIFT PREF.
0600-1400 400-2200 2200-0600
FULL TIME PART TIME  
Relatives now employed by the company (including in-laws)
 
(Please include name and relationship)
ARE YOU EITHER A U.S. CITIZEN OR A NON-CITIZEN AUTHORIZED TO WORK IN THE UNITED STATES?

Yes

No
 
 

 What foreign language do you speak fluently?
Speak
Read
Write
 Have you ever been convicted or arrested for a felony or misdemeanor?(Tickets, Etc.)

Yes

No
If yes, please describe:

 I understand and agree that I may be required to take one or more:

 Physical Examination

I agree to consent to take such test(s) at such time as designated by the company and to release the company, its directors, officers, agents, or employees from any claim arising in connection with the use of such test(s).

Yes

No

The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age but less than 70 years of age.

You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied

 
 

Position:
Date you can start (mm/dd/yy)
Salary Desired
Are you currently employed?

Yes

No
Are you commissioned with a valid card?

Yes

No
Have you ever applied with this company before?

Yes

No
Where
When
 
 
Name Location Of School
Did you Graduate?

Yes

No
Subjects of Interest
Name Location Of School
Did you Graduate?

Yes

No
Subjects of Interest
Name Location Of School
Did you Graduate?

Yes

No
Subjects of Interest
U.S. Military Service
Rank
Present Membership in National Guard or Reserves
 
 

(List your last three employers below, starting with the last one first.)
Date(MM/YY)
From To
Name
Address Of Employer
Salary
Position
Reason for Leaving
Date(MM/YY)
From To
Name
Address Of Employer
Salary
Position
Reason for Leaving
Date(MM/YY)
From To
Name
Address Of Employer
Salary
Position
Reason for Leaving
 
 

Give the name of three persons not related to you whom you have known for at least one year.
NAME
ADDRES
BUSINESS
YEARS AQUAINTED
NAME
ADDRESS
BUSINESS
YEARS AQUAINTED
NAME
ADDRESS
BUSINESS
YEARS AQUAINTED
 
 

“I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that the Company may conduct investigations, including verification of prior employment history and education, a driving record check and/or security investigation. I understand and agree that the Company may refuse to hire me or, if already hired, terminate me from employment if I provide false or misleading information in this employment application or in the hiring process.”

Yes

No
DATE (mm/dd/yy)
 
 
     
 
 
 
 
   
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