ApPLICATION FOR EMPLOYMENT
PRE-EMPLOYMENT QUESTIONNAIRE
EQUAL OPPORTUNITY EMPLOYER
PERSONAL INFORMATION
DATE
EMPLOYMENT DESIRED
EDUCATION HISTORY
GENERAL INFORMATION
FORMER EMPLOYERS (LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)
Bt-
9661
APR 1998
APPLICATION FOR EMPLOYMENT
CONTINUED ON OTHER SIDE
------
-~---
NAME (LAST NAME FIRST)
I
SOCIAL SECURITY NO. -
PRESENT ADDRESS
CITY
STATE
ZIP CODE
PERMANENT ADDRESS
CITY
STATE
ZIP CODE
PHONE NO.
REFERRED BY
(
)
POSITION
IDATEYOUCAN START
ISALARY DESIRED
ARE YOU
DYES
DNO
IIF so, MAY WE INQUIRE
DYES
DNO
EMPLOYED?
OF YOUR PRESENT EMPLOYER?
EVER APPLIED TO
DYES
DNO
IWHERE?
IWHEN?
THIS COMPANY BEFORE?
NAME&iLiOCATIONOESCHOOL
.ii
yeARS
'OIDYQU
SUBJECTS STUDIED
GRADUATE?
GRAMMAR SCHOOL
HIGHSCHOOL
COLLEGE
TRADE, BUSINESS OR
CORRESPONDENCE
SCHOOL
SUBJECTS OF SPECIAL STUDY/RESEARCH
WORK OR SPECIAL TRAINING/SKILLS
U.S. MILITARY OR
RANK
NAVAL SERVICE
DATE
INAME&ADDRESS
OFE:MPLOYER
':;';-i.ii,i;:;';.){
MONTHANOYEAR
'...""",......
FROM
i
TO
FROM
TO
FROM
TO
FROM
TO
REFERENCES GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.
YEARS
KNOWN
AUTHORIZATION
"Icertifythatthe 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.
Iauthorize 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 amannerpro-
hibitedbythe Americans with Disabilities Act (ADA) and other relevant federal and state laws."
DATE
SIGNATURE
INTERVIEWED BY
DATE
DO NOT WRITE BELOW THIS LINE
REMARKS
NEATNESS
CHARACTER
PERSONALITY
ABILITY
HIRED
FOR
DEPT.
POSITION
WILL
REPORT
SALARY
WAGES
APPROVED: 1.
2.
3.
GENERAL MANAGER
EMPLOYMENT MANAGER
DEPARTMENT HEAD
This application for employment is sold only for general use throughout the United States. Adams assumes no responsibility and hereby disclaims any liability for the inclusion in this
form of any questions or requests for information upon which a violation of local, state, andlorfederallaw maybe based. It is the user'sresponsibility to ensure that this form'susecom-
plies with applicable laws, which change from time to time.
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