Application for Employment Pre-employment questionnaire - an equal opportunity employer - all applicants must pass a background check PERSONAL INFORMATION Full Name Social Security No. Present Address City State Zip Code Permanent Address City State Zip Code Phone No. Email Referred By EMPLOYMENT DESIRED Position 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? Do you prefer part time or full time? Part time Full time If part time, what days are you available: Sun Mon Tue Wed Thu Fri Sat Can you work weekend parties? YES NO EDUCATION HISTORY Name and 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: U.S. Military or Naval Service Rank FORMER EMPLOYERS (list below last four emp;loyers, starting with last one first) Dates Name and Address of Employer Salary Position Reason for Leaving REFERENCES (Give below the names of three persons not related to you, whom you have known at least one year) Name Address Business Years Known 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 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 have read and acknowledge the above statements: YES NO        Date: