Application for Employment

Pre-Employment Questionnaire
Equal Opportunity Employer

Applicants are considered for all positions without regard to race, color, sex, creed, religion, national origin, age, marital or veteran status or the presence of a non-job related medical condition or disability, handicap, or sexual preference.

Personal Information -------


Name(Last name First)

Social Security No

Present Address



Zip Code

Permanent Address



Zip Code

Phone Number

Secondary Phone Number

Referred By

Have you ever been convicted of a felony?
Yes    No

If yes, explain:

Are you on a layoff?
Yes    No

Are you subject to recall?
Yes    No

Person to be notified in case of an emergency


Telephone #:

Employment Desired -------



Date You Can Start

Salary Desired

Are You Employed Now?
Yes    No

If So, May We Inquire Of Your Present Employer?
Yes    No

Ever Applied To This Company Before?
Yes    No



Shifts available
1st    2nd    3rd

Will you work weekends?
Yes    No

Will you work overtime?
Yes    No

Are you applying for:
Full Time    Part Time

If under 18, can you furnish a work permit?
Yes    No

Permit #:

Have you ever worked for us before?
Yes    No

If yes, when?

Reason for leaving:

Education History -------

Name & Location Of School Major Course(s) of Study: Highest Grade Completed: Did You Graduate Degree or diploma: Special Activities:
High School
Graduate School
Trade, Business, or Correspondence School

Continuing Education:

Skills -------

Describe all skills that would be of benefit in the job for which you are applying. (Example: Equipment or machines you’ve operated and for how long; computer software that you’ve used; any foreign languages you speak; supervising experience; special certifications you hold, etc.)

Former Employers -------

Most Recent Employment First

Name & Address of Employer Type of Business/Industry: Telephone: Weekly pay start: Weekly pay final: Reason for Leaving Name of Supervisor Job Title & Duties

List employer you do not want us to contact:


Military -------

Service Record

Duties and Special Training

Branch of Service:

Active Duty:

Date of Discharge:

Rank at Discharge:

References (Give below the names of three persons not related to you, whom you have known at least on year)

Name Address Phone Relationship to you and years acquainted


Do you understand the Company’s description of the essential tasks of the job for which you are applying?
Yes    No

Are you able to perform the essential functions of the position for which you are applying with or without an accommodation?
With an Accommodation    Without an Accommodation

If you will need an accommodation, please describe the accommodation(s):

Employment Application Certification

  1. The information I have provided in this application for employment is complete, true, and correct to the best of my knowledge and belief. I understand that any misinterpretation or omission of facts or any false or misleading information given in my application or during the interview process is grounds for disqualification from consideration for employment; or, in the event I am hired and the falsification is subsequently discovered, I understand that I am subject to immediate dismissal.
  2. I understand and agree that, if hired, there may be times when it will be mandatory that I work overtime, shift work, rotating shift schedule, or a work schedule other than Monday through Friday as a condition of continued employment. I agree that, if hired, I will work the hours and schedule assigned to me.
  3. I understand that, if hired, this application for employment is not a contract of employment and that any employment is at will and for an indefinite period of time.
  4. This application is current for only sixty (60) days. If I have not heard from the Company at the conclusion of this time and still wish to be considered for employment, I understand that it will be necessary for me to fill out a new application.


Applicant’s Signature:

Authorization to Verify Application

Read carefully before signing.

I understand that all statements made on my application for employment are subject to verification. I, therefore, authorize investigation of all statements contained in my application regarding prior employment and education and hereby authorize any former employer or school that I attended which is not listed on my application to give you any information regarding my prior work performance and employment or education, whether or not such information is in its files or records, or provided by personal recollection. In consideration of your review of my application for employment, I agree that any former employer or school, its officers, agents, and employees, or anyone else providing information is hereby released and forever discharged from any liability whatsoever in connection with the disclosure of that information. I authorize you to contact the personal references listed in my application whom I also release and forever discharge from any liability whatsoever for providing information about me to you. I authorize use of photocopies of this original document to be used in securing references.


Applicant’s Signature:

Print Name:

Social Security Number:

In order to facilitate our receiving reference information, please indicate below if you used a different name during any former employment or while attending school.

Print Former Name:

Sign Former Name:

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