Application For Employment

Pre- Employment Questionnaire - An Equal Opportunity Employer

Personal Information

First Name*

Last Name*

Middle

Email Address*

Phone Number*

Social Security Number*

Present Address

Street*

City*

State*

Zip*

Permanent Address

Street2

City2

State2

Zip2

Are you 18 years or older?

Yes No

Are you prevented from lawfully becoming employed in this country because of visa or immigration status?

Yes No

Employment Desired

Position*

Date 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?

Education

Grammer School - Name and location of school? Number of years attended? Did you graduate? Subjects studied?

High School - Name and Location of School? Number of years attended? Did you graduate? Subjects studied?*

College - Name and Location of School? Number of years attended? Did you graduate? Subjects studied?

General

Subjects of special study or research work

Special Skills

Activities (Civic athletic) Exclude organizations, the name of which indicates the race, creed ,sex, age marital status, color or nation of origin of its members.

US Military or Naval Service

Rank

Present membership in National Guard or Reserves

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

Former Employers - List the last three employers, starting with last one first - Date (month and year), Name and Address of Employer, Salary, Position, and Reason for leaving.

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. Include name, address, business and years acquinted.

The following statement applies in Minnesota- It is unlawful in the state of Minnesota to require or administe a lie detector test as a condition of employment or continued employment, an employer who violates this law shall be subject to criminal penalti

Signature - Formal application will require signature

In case of emergency notify:

"I certify that all the information submitted by me on this application is true and complete, and I understand tha if any false information, omissions, or misrepresentations are discovered. My application may be rejected and, if I am employed, my employm

Date and Signature - original will be required