APPLICATION FOR EMPLOYMENT

Pre-Employment Questionnaire

NAME:

PRESENT ADDRESS

PERMANENT ADDRESS

SPECIAL QUESTIONS

EDUCATION

Grammar School 

High School

College

Trade Business Correspondence 

General Subjects of 

Study or Research Work

The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to 

individuals who are at least 40 but less than 70 years of age.

FORMER EMPLOYERS  (List last employer first)

DATE

1.   TO:

FROM:

4.   TO:

FROM: 

REFERENCES:  Names of 3 persons not related to you, whom you have known at least one year.

2.

3. 

PHYSICAL RECORD:    

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 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 ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU.  I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE.