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PRE-EMPLOYMENT APPLICATION

Our Company is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color religion, national origin, veteran status, and disability as defined in the Americans with Disabilities Act, or for any other reason protected by State or Federal law.

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
   
Date:  
Name:  
Present Address:  
Contact Information:  
Are you 18 years of age or older?   Yes No
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 been convicted of any crime within the last 10 years (excluding minor traffic violations) including driving under the influence of alcohol or drugs?   Yes No
If Yes, state the offense, location, date and disposition

Do you have the ability, with or without reasonable accommodations, to work overtime or to travel if travel and/or overtime are required by the job for which you are applying?   Yes No
If No, please explain


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 to 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 or unwilling to work?   Yes No

If Yes, please specify those days or hours you would be unable or unwilling to work

Is there any type of work which you will not perform?   Yes No
If Yes, please explain


EDUCATION
Name Address and Location
  
Graduate?
Courses Studied
High School
Highest grade
completed
Yes No
Diploma
College
Number of years
completed
Yes No
Major, Minor, Degrees(s)
Trade School
Number of Months
attended
Yes No
Diploma or Certificate

If you did not graduate, why did you leave high school or college?

Are you planning to pursue further studies?   Yes No
If so, when, where and what courses?

List any scholastic honors and activities you were involved in during high school and college. (Please exclude those which may reflect race, sex, color, religion, national origin, disability, sexual orientation or other protected status)

Please describe any other special courses, seminars or training which would enable you to perform the position for which you are applying.


MILITARY
Have you ever served in the military?   Yes No
Service Branch     Final Rank  
What duties, training or experience did you have while in the military which may be job related?


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 not, explain which tasks

Have you filed any type of fraudulent claim against any of your present or past employers?   Yes No
If Yes, explain

Will you abide by the safety rules of this company?   Yes No

Have you ever been disciplined for violating company safety rules or regulations?   Yes No
If Yes, explain

How many days of work (or school) have you missed in the last two years?  
How many times have you been late for work (or school) in the last two years?  

Consistent attendance and punctuality are essential requirement of every job in our company. 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

Have you ever been disciplined or received verbal or written warnings for absenteeism or tardiness?   Yes No
If Yes, please explain.

Have you ever been fired, or asked to resign from a job?   Yes No
If Yes, please explain.


WORK HISTORY
List name 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


Name of Employer:  
Address:  
Telephone w/Area Code:  
Title:  
Describe duties performed, skills used/learned, advancements/ promotions earned:  
Name and Title of Last Supervisor:  
Dates Employed:  From:    To:  
Pay:  Starting:    Ending:  
Reason for Leaving:  
May we contact for a reference?   Yes No



Name of Employer:  
Address:  
Telephone w/Area Code:  
Title:  
Describe duties performed, skills used/learned, advancements/ promotions earned:  
Name and Title of Last Supervisor:  
Dates Employed:  From:     To:  
Pay:  Starting:     Ending:  
Reason for Leaving:  
May we contact for a reference?   Yes No



Name of Employer:  
Address:  
Telephone w/Area Code:  
Title:  
Describe duties performed, skills used/learned, advancements/ promotions earned:  
Name and Title of Last Supervisor:  
Dates Employed:  From:     To:  
Pay:  Starting:     Ending:  
Reason for Leaving:  
May we contact for a reference?   Yes No



Name of Employer:  
Address:  
Telephone w/Area Code:  
Title:  
Describe duties performed, skills used/learned, advancements/ promotions earned:  
Name and Title of Last Supervisor:  
Dates Employed:  From:     To:  
Pay:  Starting:     Ending:  
Reason for Leaving:  
May we contact for a reference?   Yes No



SUPPLEMENTAL EMPLOYMENT INFORMATION
If you worked in any of your previous positions under another name, please give that name (s) below:
(For reference checking purposes)
Name:    @ Company:       Name:    @ Company:  
Are you presently employed?   Yes No      If Yes, may we contact your present employer?   Yes No

Please list all periods of time since high school or college during which you were not employed:

How did you spend this time?


SPECIAL SKILLS
What languages do you speak fluently?  
Do you type?   Yes No      Words per minute:  

Please list all software programs in which you are proficient, indicating how many years work experience you have with each:

List other computer skills, programming languages, or computer training you have had:

List other technical training, skills or work experience which may qualify you for a job with us:

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 a position with us.


REFERENCES - Give three references, not relatives or former employers.
Name
Address
Phone
Occupation


ADDIDAVIT
   I certify that my answers to the foregoing questions are true and correct without any consequential omission 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 cause 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 a continued employment and refusal to take such test when asked will be grounds of 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.