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Pre-Employment Application

Our Company is an equal opportunity employer and will consider all applicants for all positions without regard to their race, sex, age, color, religion, national origin, veteran status or any disability as provided in the Americans With Disabilities Act.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.

Personal
First Name:
M.I.:
Last Name:
Phone:
SSN:
Over 18?:
Yes No
     
 
     
Address:
City:
State:
Zip:
           
Are you a citizen of the U.S. or do you have the legal right to be employed in the United States? Yes No
Have you ever been convicted of any crime (excluding minor traffic violations) including DWI? Yes No
If yes, state the offense, location, date and disposition:

** NOTE: A conviction will not necessarily disqualify you from employment.
           

Do you have the ability, with or without reasonable accommodations, to work over time or to travel if travel and/or overtime are required by the job for which you are applying?

Yes No
If no, please explain:
           
Would you be willing to relocate? Yes No
           
Drivers License:
State:
Type:
Currently valid? Yes No
 
Employment Desired
Are you seeking: Full-Time Part-Time Temporary or Summer Employment
Position applied for:
Salary Desired:
Date Available to Start:
   
       
Have you ever applied with our company before? Yes No
Have you ever worked for our company before? Yes No
If your answer to either of the above questions is Yes, state when and where you applied and/or worked:
       
How did you learn of our company and/or position?:
       
Are you now, or do you expect to be working in any other business or job? Yes No
Are there any days or hours you would be unable to work? Yes No
If Yes, please specify those days or hours you would be unable or unwilling to work:
       
Education
High School      
Name:
Address / Location:
Graduate?
 Yes No
Diploma:
College      
Name:
Address / Location:
Graduate?
 Yes No
Degree:
Trade School      
Name:
Address / Location:
Graduate?
 Yes No
Degree:
If you did not graduate, why did you leave?
Are you planning to pursue further studies? Yes No
If Yes, when and what courses?
List any scholastic honors, offices held and activities involved in during high school and college:
List and describe any other School or Specialized Training:
       
Military
Have you ever served in the military? Yes No
Service Branch:
Date Entered:
Date Separated:
Final Rank:
       
Capability/Reliability
Would you be willing and able to perform all of the tasks required by the job you are applying for? Yes No
If No, please explain which tasks:
Have you filed any type of fraudulent claim against any of your present or past employers? Yes No
If Yes, please explain:
Will you abide by the safety rules of this company? Yes No
Have you ever been disciplined for violating company safety rules and regulations? Yes No
If Yes, please explain:
How many days of work (or school) have you missed in the past 2 years?
How many times have you been late for work (or school) in the past 2 years?
Would you be willing and able to report to work on time every day on a regular and consistent basis? Yes No
If No, please explain:
       

Work History

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.
PLEASE GIVE MONTH AND YEAR. DO NOT REFERENCE YOUR RESUME.
   
Position 1
Employer:
Address:
City:
State:
Zip:
Nature of Business:
Phone :
Title
    
Duties:
Supervisor Name:
Supervisor Title:
Dates Employed:
Month
Year
Pay
From:
Starting $:
To:
Ending $:
Reason for Leaving:
 
Position 2
Employer:
Address:
City:
State:
Zip:
Nature of Business:
Phone :
Title
    
Duties:
Supervisor Name:
Supervisor Title:
Dates Employed:
Month
Year
Pay
From:
Starting $:
To:
Ending $:
Reason for Leaving:
 
Position 3
Employer:
Address:
City:
State:
Zip:
Nature of Business:
Phone :
Title
    
Duties:
Supervisor Name:
Supervisor Title:
Dates Employed:
Month
Year
Pay
From:
Starting $:
To:
Ending $:
Reason for Leaving:
 
Position 4
Employer:
Address:
City:
State:
Zip:
Nature of Business:
Phone :
Title
    
Duties:
Supervisor Name:
Supervisor Title:
Dates Employed:
Month
Year
Pay
From:
Starting $:
To:
Ending $:
Reason for Leaving:
 
Supplemental Employment Information
If you worked in any of your previous positions under another name, please give that name(s):
Are you presently employed? Yes No
If Yes, may we contact your present employer? Yes No
Have you ever been fired or asked to resign from a job? Yes No
If Yes, please explain:
 
Special Skills
Do you type? Yes No Words per minute:
Do you take shorthand? Yes No Words per minute:
Have you had any computer or word processing training? Yes No
If Yes, please explain:
What languages do you speak fluently?
Use this space below to describe why you are interested in working for our company and to list those skills and abilities which you feel particularly qualify you for this position with us.
       
References
Give 3 references, not relatives or former employers.
 
Name
Address
Phone
Occupation
1
2
3
       
Affidavit

I certify that my answers to the forgoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading, or otherwise incorrect statements made on this application form or during any interviews may be grounds for my immediate discharge.

I hereby authorize the Company to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation.In addition, I hereby waive my right to bring any case of action against these individuals for defamation, invasion of privacy or any other reason because of their statements.

I agree that, if I am employed, I will abide by all the rules and regulations of the company. I understand that the taking of drug and alcohol tests, when given pursuant to company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for my immediate termination. I further understand that nobody in the Company is authorized to enter into any written or verbal employment contracts with me for any definite period of time without the express written consent of the President of the Company. I also understand that my employment is "at-will" and may be terminated by myself or by the company at any time for any reason or no reason at all, with or without prior notice.

Please print your full name to act as your digital signature.

By submitting this form you agree to the above statement.