App
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APPLICATION FOR (AN EQUAL OPPORTUNITY EMPLOYER) EMPLOYMENT
(PRE-EMPLOYMENT QUESTIONNAIRE)
PERSONAL INFORMATION N AME
LAST
FIRST
PRESENT ADDRESS
STREET
PERMANENT ADDRESS
STREET
MIDDLE
D ATE SOCIAL NUMBE SECURITY R
CITY CITY
PHONE NO
ARE YOU 18 YEARS OR OLDER?
STATE
ZIP
STATE
ZIP
Yes
ARE YOU EITHER A U.S. CITIZEN OR AN ALIEN AUTHORIZED TO WORK IN THE UNITED STATES?
EMPLOYMENT DESIRED
DATE CAN YOU START IF SO MAY WE
POSITIO N ARE YOU EMPLOYED NOW?
No Yes
No
SALARY DESIRE D
PF YOUR PRESENT INQUIRE EMPLOYER?
EVER APPLIED TO THIS COMPANY BEFORE?
WHERE ?
WHEN ?
REFERRED BY
EDUCATION
NAME AND LOCATION OF SCHOOL
GRAMMAR SCHOOL
*NO YEAR OF ATTENDE S D
*DID GRADUATE YOU ?
SUBJECTS STUDIED
HIGH SCHOOL COLLEG E TRADE, BUSINESS CORRESPONDEN OR CE SCHOO L
GENERAL SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK
SPECIAL SKILLS ACTIVITIES (CIVIC, ATHLETIC, ETC)
EXCLUSIVE ORGANIZATION S, THE NAME OF WHICH INDICATES THE RACE, GREED U.S. MILITARY SEX, AGE, NAVAL MARITAL OR STATUS, COLOR SERVICE OR NATION OF ORIGIN OF ITS MEMBERS *The Age
Discrimination in Employment Act of 1987 prohibits discrimination TOPS FORM 3285 on the basis of (89-8) age with respect to individuals who are at least 40 years of age TOPS
R ANK
(CONTINUED ON OTHER SIDE)
PRESENT NATIONAL GUARD OR MEMERSHIP IN RESERVES
LITHO IN U.S.A
PERSONAL EMPLOYERS DATE MONTH , AND YEAR F ROM TO
(LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).
NAME AND REASON ADDRESS FOR LEAVING OF EMPLOYER
SALARY
POSITIO N
F ROM TO F ROM TO F ROM TO WHICH OF THESE JOBS DID YOU LIKE BEST?
REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR
N AME
ADDRES S
YEAR ACOUAINTE S D
BUSINES S
1. 2. 3. THE FOLLOWING STATEMENT APPLIES IN MARYLAND & MASSACHUSETTS (Fill in name IT IS UNLAWFUL IN THE STATE OF _______________________ TO REQUIRE OR ADMINISTER A LIE DETECTOR of state) CONDITION TEST AS A OF EMPLOYMENT OR CONTINUED EMPLOYMENT, AN EMPLOYER WHO VIOLATES THIS SUBJECT TOBE CRIMINAL PENALTIES AND CIVIL LAW SHALL LIABILITY Signature of Applicant
IN CASE EMERGENCY OF NOTIFY
N AME
ADDRES S
PHONE NO.
“I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS KNOWLEDGE AND FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVEALL AND YOUINFORMATION ANY CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY LEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME HAVE, AND RETO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE PAYMENT DATE OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE.”
D ATE
SIGNATUR E
DO NOT WRITE BELLOW THIS LINE INTERVIEWED BY
D ATE
REMARK S
NEATNES S HIRE D: SALARY /
ABILIT Y Yes
No
POSITIO N
DE PT. DATE REPORTING TO
for WAGE WORK Employment This form Form is sold has APPROVE 1. 2. 3. been for general designed to use D strictly EMPLOYMENT DEPT. comply with throughout MANAGER HEAD State the United and Federal TOPS States. fair employment assumes no whish, when practice responsibility lawsasked by the Employment of the Job Applicant, may violate State and/or Federal Law prohibiting for the employment inclusion in discrimination. said form of This questions any Application
GENERAL MANAGER
(PRE-EMPLOYMENT QUESTIONNAIRE)
PERSONAL INFORMATION N AME
LAST
FIRST
PRESENT ADDRESS
STREET
PERMANENT ADDRESS
STREET
MIDDLE
D ATE SOCIAL NUMBE SECURITY R
CITY CITY
PHONE NO
ARE YOU 18 YEARS OR OLDER?
STATE
ZIP
STATE
ZIP
Yes
ARE YOU EITHER A U.S. CITIZEN OR AN ALIEN AUTHORIZED TO WORK IN THE UNITED STATES?
EMPLOYMENT DESIRED
DATE CAN YOU START IF SO MAY WE
POSITIO N ARE YOU EMPLOYED NOW?
No Yes
No
SALARY DESIRE D
PF YOUR PRESENT INQUIRE EMPLOYER?
EVER APPLIED TO THIS COMPANY BEFORE?
WHERE ?
WHEN ?
REFERRED BY
EDUCATION
NAME AND LOCATION OF SCHOOL
GRAMMAR SCHOOL
*NO YEAR OF ATTENDE S D
*DID GRADUATE YOU ?
SUBJECTS STUDIED
HIGH SCHOOL COLLEG E TRADE, BUSINESS CORRESPONDEN OR CE SCHOO L
GENERAL SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK
SPECIAL SKILLS ACTIVITIES (CIVIC, ATHLETIC, ETC)
EXCLUSIVE ORGANIZATION S, THE NAME OF WHICH INDICATES THE RACE, GREED U.S. MILITARY SEX, AGE, NAVAL MARITAL OR STATUS, COLOR SERVICE OR NATION OF ORIGIN OF ITS MEMBERS *The Age
Discrimination in Employment Act of 1987 prohibits discrimination TOPS FORM 3285 on the basis of (89-8) age with respect to individuals who are at least 40 years of age TOPS
R ANK
(CONTINUED ON OTHER SIDE)
PRESENT NATIONAL GUARD OR MEMERSHIP IN RESERVES
LITHO IN U.S.A
PERSONAL EMPLOYERS DATE MONTH , AND YEAR F ROM TO
(LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).
NAME AND REASON ADDRESS FOR LEAVING OF EMPLOYER
SALARY
POSITIO N
F ROM TO F ROM TO F ROM TO WHICH OF THESE JOBS DID YOU LIKE BEST?
REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR
N AME
ADDRES S
YEAR ACOUAINTE S D
BUSINES S
1. 2. 3. THE FOLLOWING STATEMENT APPLIES IN MARYLAND & MASSACHUSETTS (Fill in name IT IS UNLAWFUL IN THE STATE OF _______________________ TO REQUIRE OR ADMINISTER A LIE DETECTOR of state) CONDITION TEST AS A OF EMPLOYMENT OR CONTINUED EMPLOYMENT, AN EMPLOYER WHO VIOLATES THIS SUBJECT TOBE CRIMINAL PENALTIES AND CIVIL LAW SHALL LIABILITY Signature of Applicant
IN CASE EMERGENCY OF NOTIFY
N AME
ADDRES S
PHONE NO.
“I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS KNOWLEDGE AND FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVEALL AND YOUINFORMATION ANY CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY LEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME HAVE, AND RETO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE PAYMENT DATE OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE.”
D ATE
SIGNATUR E
DO NOT WRITE BELLOW THIS LINE INTERVIEWED BY
D ATE
REMARK S
NEATNES S HIRE D: SALARY /
ABILIT Y Yes
No
POSITIO N
DE PT. DATE REPORTING TO
for WAGE WORK Employment This form Form is sold has APPROVE 1. 2. 3. been for general designed to use D strictly EMPLOYMENT DEPT. comply with throughout MANAGER HEAD State the United and Federal TOPS States. fair employment assumes no whish, when practice responsibility lawsasked by the Employment of the Job Applicant, may violate State and/or Federal Law prohibiting for the employment inclusion in discrimination. said form of This questions any Application
GENERAL MANAGER
