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Application for Employment

Pre-Employment Questionnaire- An Equal Opportunity Employer

 

1. PERSONAL INFO
Name (last name first): *
Social Security No:
Present Address:
City:
State:
Zip:
Permanent Address:
City:
State:
Zip:
Phone: *
Are you 18 years or older? Yes No

2. DESIRED EMPLOYMENT:

Position:
When 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 

Where:

When:
Ever worked for this company before? Yes No 

Where:

When:
Reason for leaving:
Name of last supervisor at this company:
Who referred you to this company?

Employment Agency 

Friend 

Newspaper/Advertising 

State Employment Office 

College Placement

Walk In

Other

3. EDUCATION:

Grammar School  (Name & Location):
No. of years attended: Graduated? Yes No 
Subjects Studied:

High School 

(Name & Location):
No. of years attended: Graduated? Yes No 
Subjects Studied:

College

  (Name & Location):
No. of years attended: Graduated? Yes No 
Subjects Studied:

Trade, Business, or Correspondence School (Name & Location):
No. of years attended: Graduated? Yes No 
Subjects Studied:

4. GENERAL:

Subjects of special study or research work:
Special Training:
Special Skills:

5. REFERENCES:

Below, give the names of three persons you are NOT related to, whom you have known at least one year.

Name:
Address:
Business:
Years Acquainted:

Name:
Address:
Business:
Years Acquainted:

Name:
Address:
Business:
Years Acquainted:

6. FORMER EMPLOYERS:

List below last three employers, starting with the most recent one first.
Name of Present or Last Employer:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Salary:
Weekly Final Salary:
May we contact your supervisor? Yes No
Name of Supervisor:
Title:
Phone:
Description of Work:
Reason for Leaving:
Name of Previous Employer:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Salary:
Weekly Final Salary:
May we contact your supervisor? Yes No
Name of Supervisor:
Title:
Phone:
Description of Work:
Reason for Leaving:
Name of Previous Employer:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Weekly Starting Salary:
Weekly Final Salary:
May we contact your supervisor? Yes No
Name of Supervisor:
Title:
Phone:
Description of Work:
Reason for Leaving:

 

7. SERVICE RECORD:

Branch of Service:

Discharge Date/Rank

 

Have you been convicted of a felony in the last 5 years?  YesNo
If yes, explain.  (Will not necessarily exclude you from consideration.)  
E-mail Address:  *

*denotes required fields