Pre-employment Application

PRE-EMPLOYMENT APPLICATION

PERSONAL INFORMATION Social Security #:       Name:       Present Address:      

Date:      

Permanent Address (if different from present):      Contact Information: Home:       Cell:       Work:       Can we contact you at this number Yes No Are you 18 years of age or older? Yes No If hired, can you provide written evidence that you are authorized to work in the U. S. ? Have you ever been convicted of any law violation? Yes No If Yes, explain: (conviction of an offense will not necessarily disqualify you from consideration):       Do you have any physical limitations that preclude you from performing any work for which you are considered? If Yes, what can be done to overcome your limitations:       Have you ever been discharged or forced to resign from a job? If Yes, explain:       EMPLOYMENT DESIRED Type of work desired:       Salary desired:       Desired schedule: Full Time Part Time How were you referred to our organization:       Date you would be available to start:       Are you presently employed? If Yes, may we enquire from your current employer? Do you have any relatives that are employed by this organization:

Yes

No

Yes

No

Temp Yes Yes Yes

No No No

Please specify:      

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Is there any information we would need about your name, or use of another name, for us to be able to check your work record? Yes No Please specify:       Please list any additional information that relates to your ability to perform the job for which you have applied, such as special training, skills, licenses, hobbies, etc.:     

SPECIALIZED TRAINING: Word Processing: Spreadsheets Database: Typing: Dictation: Short Hand: Programming:

No No No No No No No

Specify:       Specify:       Specify:       Specify:       Specify:       Specify:       Specify:      

No No No No

Specify:       Specify:       Specify:       Specify:      

OTHER COMPUTER SKILLS Able to log-on to LAN Able to access/save documents on shared folder over LAN Able to work with form fields in Microsoft Word Able to utilize mail merge function in Microsoft Word Able to select printer over LAN Able to select printer paper source over the network Able to send fax from local workstation Able to manage contacts in Microsoft Outlook

Yes Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes

COMPUTER APPLICATIONS TRAINING: Lytec: Yes Outlook: Yes Adobe Yes Palm Desktop Yes

EDUCATION Type

Name/Location

Course of Study

Elementary & Jr. High High School

     

No No No No No No No No Degree/Diploma

     

# Years Completed      

     

     

     

     

College

     

     

     

     

Technical or Other

     

     

     

     

     

EMPLOYMENT RECORD Company Position Name/Location            

Date started/left

Rate of Pay

Reason for leaving

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Location

Telephone

U.S. MILITARY SERVICE Branch of Service:       From:       Rank and Type of Service:       Training/Experience Received:      

To:      

References (please do not include relatives) Name Occupation Years Known

We consider applicants for all positions on the basis of qualifications and without regard to race, color, religion, sex, national origin, age, marital status, disability, sexual orientation, use of lawful products during non-work hours and any other legally protected status.

APPLICANT’S STATEMENT I understand that the employer follows an “employment at will” policy, in that I or the employer may terminate my employment at any time, or for any reason consistent with applicable state or federal law; this “employment at will” policy cannot be changed verbally or in writing, unless the change is specifically authorized in writing by the chief operating officer of this organization. I understand that this application is not a contract of employment. In understand that federal law prohibits the employment of unauthorized aliens; all persons hired must submit satisfactory proof of employment authorization and identity; failure to submit such proof will result in denial of employment. I understand this application will be active for a period of 1 (one) year; after that time, if I wish to be considered for employment, I must submit a new application. I understand that the employer will thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorize all individuals, schools, and firms named therein, except my current employer if so noted, to provide any information requested about me, and I release them from all liability for damage in providing this information. I certify that all the statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment.

Your Signature:_____________________________________Date:_________________

OTHER INFORMATION (The following information is voluntary and will be used for identification purposes and post-employment medical records. These items will remain confidential). Emergency Contact:       Height:       Weight:       Date of Birth:       Sex:       Marital Status:       If married, spouse /significant other:       Do you have any children?       If yes, name and age of each:      

Current Medications:       Allergies:       Medical History: