APPLICATION FOR EMPLOYMENT

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

PERSONAL INFORMATION

!-INDICATES REQUIRED INFORMATION

DATE

SOCIAL SECURITY NUMBER

LAST NAME

FIRST NAME

MIDDLE

PRESENT ADDRESS

PERMANENT ADDRESS

PHONE NO.

ARE YOU 18 YEARS OR OLDER

ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS?

EMPLOYMENT DESIRED

POSITION
DATE YOU CAN START
SALARY DESIRED
ARE YOU EMPLOYED NOW?
IF SO MAY WE INQUIRE OF YOUR PRESENT EMPLOYER
EVER APPLIED TO THIS COMPANY BEFORE?
WHERE?
WHEN?
REFERRED BY?

EDUCATION

	NAME AND LOCATION OF SCHOOL	*NO. OF YEARS ATTENDED	*DID YOU GRADUATE	SUBJECTS STUDIED
GRAMMAR SCHOOL
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS OR CORRESPONDENCE SCHOOL

GENERAL

SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK
SPECIAL SKILLS
ACTIVITIES: (CIVIC, ATHLETIC, ETC.)
EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED, SEX, AGE, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS.
U.S. MILITARY OR NAVAL SERVICE
RANK
PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES

FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).

DATE MONTH AND YEAR	NAME AND ADDRESS OF EMPLOYER	SALARY	POSITION	REASON FOR LEAVING

FROM
TO
FROM
TO
FROM
TO

WHICH OF THESE JOBS DID YOU LIKE BEST?
WHAT DID YOU LIKE MOST ABOUT THIS JOB?

REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.

NAME	ADDRESS	BUSINESS	YEARS ACQUAINTED

THE FOLLOWING STATEMENT APPLIES IN MARYLAND & MASSACHUSETTS. (FILL IN NAME OF STATE)

IT IS UNLAWFUL IN THE STATE OF TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.

SIGNATURE OF APPLICANT

IN CASE OF EMERGENCY NOTIFY
NAME	ADDRESS	PHONE NO.

"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 TE COMPANY. I UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAT ITS 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"

DATE
SIGNATURE

*THIS FORM HAS BEEN REVISED TO COMPLY WITH THE PROVISIONS OF THE AMERICANS WITH DISABILITIES ACT AND THE FINAL REGULATIONS AND INTERPRETIVE GUIDANCE PROMULGATED BY THE EEOC ON JULY 26, 1991

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