Form Page: statepipe

APPLICATION FOR EMPLOYMENT

(PRE-EMPLOYMENT QUESTIONNAIRE) (AN EQUAL OPPORTUNITY EMPLOYER)

PERSONAL INFORMATION

Date:

Name:

Present Address:

Permanent Address:

Phone Number:

Are you 18 years or older?

Are you prevented from lawfully becoming employed in this country because of Visa or Imigration Status?

EMPLOYMENT DESIRED

Position:

Date you can start:

Salary Desired:

Are you employed now?

If so may we inquire of your present employer?

If so, when did you apply?

Have you ever applied to this company before?

Referred by:

EDUCATION

Name & Location

No of years attended

Subjects Studied

Did you graduate?

Grammar School

High School

College

Trade, Business or Correspondance

GENERAL

Subjects of special study or research work:

Special skills:

Activities (Civic, Athletic, etc.):

US Military or Naval Service:

FORMER EMPLOYERS

(List below last three employers, starting with last one first)

Employer #1

From / To:

Name and Address:

Salary:

Position:

Reason for Leaving:

Employer #2

From / To:

Name and Address:

Salary:

Position:

Reason for Leaving:

Employer #3

From / To:

Name and Address:

Salary:

Position:

Reason for Leaving:

Employer #4

From / To:

Name and Address:

Salary:

Position:

Reason for Leaving:

Which of these jobs did you like best?

What did you like most about this Job?

REFFERENCES: Give the names of three plersons not related to you, whom you have known at least one year.

NAME

ADDRESS

BUSINESS

YEARS
ACQUAINTED

In case of emergency notify:

RESUME:

AUTHORIZATION

"I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and i agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than it's president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing."

*REQUIRED

*In Checking this box you "CERTIFY" that the above information is correct. This is in lieu of your signature.

*Email:

*Date:

Yes

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