Application for Employment

PRE-EMPLOYMENT QUESTIONNAIRE
EQUAL OPPORTUNITY EMPLOYER

Personal Information

DATE
NAME (LAST NAME FIRST)
SOCIAL SECURITY NO.
PRESENT ADDRESS
CITY
STATE
ZIP CODE
PERMANENT ADDRESS
CITY
STATE
ZIP CODE
PHONE NO.
SECONDARY PHONE NO.
REFERRED BY

Employment Desired

Position
DATE YOU CAN START
ARE YOU EMPLOYED NOW?
IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?
EVER APPLIED TO
THIS COMPANY BEFORE?
Where
When

Education History

NAME & LOCATION OF SGHOOL
Years
Attended
Did you
Graduate
Subjects Studied
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS, OR
CORRESPONDENCE
SCHOOL

General Information

SUBJECT OF SPECIAL STUDY/RESEARCH WORK
SPECIAL TRAINING
SPECIAL SKILLS
U.S. MILITARY OR RANK NAVAL SERVICE
Rank

former Employers (UST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)

DATE
MONTH AND YEAR
NAME & ADDRESS OF EMPLOYER
POSITION
REASON FOR LEAVING
From
TO
From
TO
From
TO
From
TO

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. authorize investigation of all statements contained herein and the references and employers listed above to give you any and all in- formation 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. | 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. | understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, | understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization fram me to consent to these reports. | also understand that a poor credit history or conviction will not automatically result in disqualification from employment.” In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to com- plete the required employment eligibility verification document form upon hire.

Date
SIGNATURE

Do Not Write Below This Line

Date
INTERVIEWED BY

Remarks.

NEATNESS
CHARACTER
PERSONALITY
ABILITY
HIRED
FOR DEPT.
POSITION
WILL REPORT
SALARY WAGES
APPROVED:
EMPLOYMENT MANAGER
DEPARTMENT HEAD
GENERAL MANAGER

This application far employment is sold only for genera! use throughout the United States. TOPS assumes no responsibility and hereby disclaims any lability for the inclusion in this form of any questions or requests for information upon which a violation of local, state, and/or federal law may be based. Itis the user’s responsibility to ensure that this form's use complies with applicable laws, which change from time to time.