APPLICATION FOR EMPLOYMENT

(PRE-EMPLOYMENT QUESTIONAIRE) (AN EQUAL OPPORTUNITY EMPLOYER)

PERSONAL INFORMATION

Last Name	First Name

Present Address: Street	City	State		Zip Code

Permanent Address: Street	City	State		Zip Code

Phone No.		Are you 18 years of age or older?	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?

Referred by:

EDUCATION	Name and Location of School	*No of Years Attended	*Did you Graduate?	Subjects Studied
Grammar School			Yes No
High School			Yes No
College			Yes No
Trade, Business, or Correspondence School			Yes No

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 Yes No

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

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 for at least one year.

NAME	ADDRESS	BUSINESS	YEARS ACQUAINTED
1.
2.
3.

In case of emergency notify: NAME: ADDRESS: PHONE NUMBER:

By submitting this form, "I certify that all the information submitted by me on this application is true and complete,and i understand that any false information, ommisions, or misrepresentations are discovered, 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, 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 writing 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."

Do you accept this agreement? Yes No