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APPLICATION FOR EMPLOYMENT

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

PERSONAL INFORMATION

date
SOCIAL SECURITY NUMBER
NAME
last
middle
first
PRESENT ADDRESS
STREET
CITY
STATE
ZIP
PERMANENT ADDRESS
STREET
CITY
STATE
ZIP
PHONE NO.
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?
IF SO MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?
EVER APPLIED TO THIS COMPANY BEFORE?
WHERE?
WHEN?
REFERRED BY

EDUCATION

NAME AND LOCATION OF SCHOOL
NO.OF YEARS ATTENDED
*DID YOU GRADUATE?
SUBJECTS STUDIED
GRAMMAR SCHOOL
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS OR CORRESPONDENCE SCHOOL

GENERAL

SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK
SPECIAL SKILLS
ACTIVITIES: (CIVIC ATHLETIC ETC.)

EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED. SEX. AGE. MARITAL STATUS. COLOR OR NATION OF ORIGIN OF ITS MEMBERS.

U. S MILITARY OR NAVAL SERVICE
RANK
PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES

FORMER EMPLOYERS

(LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).
DATE MONTH AND YEAR
NAME AND ADDRESS OF EMPLOYER
SALARY
POSITION
REASON FOR LEAVING
FROM
TO
FROM
TO
FROM
TO
FROM
TO
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
1
2
3
THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTS. (Fill in name of state.)
IT IS UNLAWFUL IN THE STATE OF

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 of Applicant
IN CASE OF EMERGENCY NOTIFY
NAME
ADDRESS
PHONE NUMBER

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 IF I AM EMPLOYED. MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME. IN CONSIDERATION OF MY EMPLOYMENT, IAGREE 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 M 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 OIj TIME. OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.

DATE
SIGNATURE
INTERVIEWED BY:
DATE
REMARKS:
NEATNESS
ABILITY
HIRED:
Yes
No
POSITION
DEPT
SALARY/WAGE
DATE REPORTING TO WORK
APPROVED
EMPLOYED MANAGER
DEPT. HEAD
GENERAL MANAGER

This form has been designed to strictly comply with State and Faderal fair employment practice laws prohibiting employment discrimination. This Application for Employment From is sold for general use throughout the United States. TOPS assumes no responsibility for the inclusion in said form of any questin which, when asked by the Employer of the job Applicant, may violate State and/or Federal law.