Application for Employment (#4)

Application for Employment

(Pre-Employment Questionnaire) (An Equal Opportunity Employer)

Personal Information

Date

First Name

Middle Name

Last Name

Present Address

Address Line 1

Address Line 2

City

State

Zip Code

Permanent Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone No.

Are you 18 years or older?

Yes

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

Yes

Employment Desired

Position

Date You Can Start

Salary Desired

Are You Employed Now?

Yes

If So, May We Inquire Of Your Present Employer?

Yes

Ever Applied To This Company Before?

Yes

Where?

When?

Referred By

Education

Name and Location of School

* No Of Years Attended

* Did you Graduate?

Subjects Studied

Grammar School

Yes

High School

Yes

College

Yes

Trade, Business, or Correspondence School

Yes

General

Subjects of Special Study or Research Work

Special Skills

Activities: (Civic Athletics Etc.)

U.S. Military or Naval Service

Rank

Present Membership in National Guard or Reserves

Yes

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

Former Employers

(List Below Last Three Employers, Starting With Last One First)

From Date (MM/YYYY)	To Date (MM/YYYY)	Name and Address of Employer	Salary	Position	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

Name	Address	Business	Years Acquainted

The Following Statement Applies In: Maryland & Massachusetts.

It Is Unlawful In The State Of:

Choose State

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 Penalties And Civil Liability

Signature

In Case of Emergency Notify

Name

Address

Phone No.

* 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 AT ANY TIME. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE. AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY'S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. I UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT'S PRESIDENT, AND THEN ONLY WHEN IN WRONG AND SIGNED BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.

Date / Time

Signature

This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination. This Application for Employment Form is sold for general use throughout the United States. TOPS 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

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