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Personal Information - Pre-Employment Questionnaire, An Equal Opportunity Employer
Name (first, middle, last):
E-Mail:
Present Address:
Apt No.
City: State: Zip:
Phone: (example: 952-555-1212)
Permanent Address
Apt No.
City State: Zip:
Are you 21 years or older? Yes:
No:
Desired Employment
Social Security #
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 Enviromatic before? Yes: No:
If Yes, Where?: When?:
Ever worked for Enviromatic before? Yes: No:
If Yes, Where?: When?:
Reason for leaving:
Name of last supervisor at Enviromatic:
Who referred you to Enviromatic:
Education
School level-name and address of school -
Years attended - did you graduate? - Subject Studied.
High School:
College:
Other:
References
Below give the names of three persons you are not related to whom
you have known at least one year.
Name, Address, Business, Years Acquainted, Phone #
1:
2:
3:
Service Record
Branch of service:
Discharge Date: Rank:
Have you been convicted of a felony within the last 5 years?
Yes: No:
(if yes explain - will not necessarily exclude you from consideration)
Do you have a valid drivers license? Yes: No:
State issued: License Number:
(a Valid Drivers License is Required, and Driver
Must Pass Review by Our Insurance Company)
Former Employers (must list at least the last 5 years work history)
List below all previous employers starting with the most recent first.
Name of employer:
Address:
City: State: Zip:
Starting date: Leaving date:
Job title:
Starting salary: Final salary:
May we contact your supervisor: Yes: No:
Name of supervisor: Title:
Phone:
Description of work:
Reason for leaving:
Name of employer:
Address:
City: State:
Zip:
Starting date: Leaving date:
Job title:
Starting salary: Final salary:
May we contact your supervisor: Yes: No:
Name of supervisor:
Title:
Phone:
Description of work:
Reason for leaving:
Name of employer:
Address:
City: State: Zip:
Starting date: Leaving date:
Job title:
Starting salary: Final salary:
May we contact your supervisor: Yes: No:
Name of supervisor: Title:
Phone:
Description of work:
Reason for leaving:
Name of employer:
Address:
City: State:
Zip:
Starting date: Leaving date:
Job title:
Starting salary: Final salary:
May we contact your supervisor: Yes: No:
Name of supervisor: Title:
Phone:
Description of work:
Reason for leaving:
Name of employer:
Address:
City: State: Zip:
Starting date: Leaving date:
Job title:
Starting salary: Final salary:
May we contact your supervisor: Yes: No:
Name of supervisor: Title:
Phone:
Description of work:
Reason for leaving:
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.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information 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.
I also understand and agree that no representative of the company 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, unless it is in writing and signed by an authorized company representative."
Date: Name:
Click here for a printable version of this application
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