Application for Employment

Pre-Employment Questionaire from an Equal Opportunity Employer

* This form has been revised to comply with the provisions of the American Disabilites Act and the final regulations and interpretive guidance promulgated by the EEOC on July 26, 1991

Full Name (required)

Present Address (required)

Permanent Address (required)

Phone Number (required)

Are You 18 Years or Older (required)

YES

Are You Prevented from Lawfully becoming Employed in this Country because of VISA or Immigration Status? (required)

YES

Employment Position Desired (required)

Date You Can Start (required)

Salary Desired (required)

Are You Employed Now? (required)

YES

If 'YES', May We Inquire of Your Present Employer?

Have You Ever Applied to this Company Before?

When/Where? (required)

Referred By: (required)

EDUCATION: Include: Name /Location of Schools/Years Attended/Graduated/Subjects Studied. Thank You

Grammar School (required)

High School (required)

College (required)

Trade, Business or Correspondence School (required)

GENERAL EXPERIENCE

Subjects of Special Study or Research Work (required)

Special Skills (required)

Activities: (Civic, Athletic, ETC.) (required)

(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 of Naval Service. (Include Rank and Present Membership in National Guard or Reserves. (required)

FORMER EMPLOYERS: List Below, 3 Previous Employers (begin with the most recent)

Employer 1): Name/Address/Dates From-To/Salary/Position/Reason for Leaving (required)

Employer 2): Name/Address/Date From-To/Salary/Position/Reason for Leaving (required)

Employer 3): Name/Address/Dates From-To/Salary/Position/Reason for Leaving (required)

Which of these jobs did you like best? (required)

What did you like most about this job? (required)

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

Reference 1): Name/Address/Business/Years Acquainted (required)

Reference 2): Name/Address/Business/Years Acquainted (required)

Reference 3): Name/Address/Business/Years Acquainted (required)

In Case of EMERGENCY Notify: Name/Address/Phone No. (required)

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"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, flasified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

Your social security number and offical signature will only be required at time of employment. Thank You

This form has been designed to strictly comply with State and Federal fair employment proctices laws prohibiting employment discrimination. This application form is of general standard use throughout the United States and assumes no responsibility for the inclusion in said form of any questions which, when asked by the Employer of the Job Applicant, may violate State and/or Federal Law.

Additional request for job qualifications, in the form of a resume, may be required for certain positions.

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