Employment Application Page 1
Pre-Employment Questionnaire
Equal Opportunity Employer
PERSONAL INFORMATION
DATE : __________________________________________
NAME (LAST NAME FIRST )
SOCIAL SECURITY NO :
-
-
PRESENT ADDRESS
CITY
STATE
ZIP CODE
PERMANENT ADDRESS
CITY
STATE
ZIP CODE
PHONE NO :
(
)
REFERRED BY :
ARE YOU 16 OR OLDER ? [
]
YES [ ] NO
DO YOU HAVE RELIABLE TRANSPORTATION TO AND FROM WORK ?
[ ]
YES [
] NO
EMPLOYMENT DESIRED
POSITION ( CIRCLE ONE )
INSIDE COOK / DELIVERY DRIVER
DATE YOU CAN
START
SALARY DESIRED
ARE YOU EMPLOYED ?
[ ] YES [ ] NO
IF SO , MAY WE INQUIRE OF YOUR PRESENT EMPLOYER ?
[ ] YES [ ] NO
EVER APPLIED TO THIS COMPANY BEFORE ?
[ ] YES [ ] NO
WHERE ?
WHEN ?
EDUCATION HISTORY
NAME & LOCATION OF SCHOOL
YEARS
ATTENDED
DID YOU
GRADUATE ?
SUBJECTS STUDIED
GRAMMAR SCHOOL
HIGH SCHOOL
COLLEGE
TRADE , BUSINESS , OR
CORRESPONDENCE SCHOOL
GENERAL INFORMATION
SUBJECTS OF SPECIAL STUDY /RESEARCH
WORK OR SPECIAL TRAINING /SKILLS
US MILITARY SERVICE
RANK
AVAILABILITY
MON
TUES
WED
THURS
FRI
SAT
SUN
FROM
TO
REFERENCES
BELOW GIVE THE NAMES OF THREE (3) PERSONS NOT RELATED TO YOU , WHOM YOU HAVE KNOWN AT LEAST A YEAR
NAME
ADDRESS
BUSINESS
YEARS KNOWN
CONTINUED ON NEXT PAGE
Employment Application Page 2
FORMER EMPLOYERS (LIST LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)
DATE
MONTH & YEAR
NAME & ADDRESS OF
EMPLOYER
SALARY
POSITION
REASON FOR LEAVING
FROM
TO
FROM
TO
FROM
TO
FROM
TO
AUTHORIZATION :
"I certify that the facts contained in this application are true and complete to the best of my knowledge
and understand that, if employed, falsified 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 understand that Bellagios Pizza is a 'Drug-Free' Environment and that I may be subject to random,
with-cause and post-accident drug testing.
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.
I understand that employment is 'At Will', and employment may be terminated for any cause at any
time."
DATE________________
SIGNATURE________________________________________________
INTERVIEWED BY_______________________________________ DATE________________________
DO NOT WRITE BELOW THIS LINE
REMARKS :
NEATNESS
CHARACTER
PERSONALITY
ABILITY
HIRE DATE
POSITION
SALARY /WAGES
APPROVED
:___________________________
GENERAL MANAGER
download Pre-Employment Questionnaire Equal Opportunity Employer
