Application For Employment Pre-Employment Questionnaire – An Equal Opportunity Employer Personal Information First Name* Last Name* Middle Email* Phone #* Social Security #* 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* Currently 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 - Name and location, Years attended, Subjects studied, and Did you graduate? Grammar School* High School* College* General Special study or research Special skills US Military or Naval Service Rank 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 administer a lie detector test as a condition of employment or continued employment, an employer who violates this law shall be subject to criminal penalty 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 that if any false information, omissions, or misrepresentations are discovered. My application may be rejected and, if I am employed, my employment may be terminated. Date and Signature - original will be required Security
