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PRE-EMPLOYMENT QUESTIONNAIRE
EQUAL OPPORTUNITY EMPLOYER
Personal Information
*
Indicates required field
Name
*
First
Last
Phone Number
*
Referred by:
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Employment Desired
Postion Desired:
*
Date you can start:
*
Desired Wage (per hour):
*
Are you employed now?
*
Yes
No
If yes, may we contact your present employer?
*
Yes
No
Non-Applicable
Education History
High School. (name of school, did you graduate, subjects studied)
*
College. (name of school, did you graduate, subjects studied)
*
Trade, Business or Correspondence School. (name of school, did you graduate, subjects studied)
*
General Information
Subject of Special Study / Research Work
*
Special Training, Certifications, Licenses
*
Special Skills, Foreign Languages, Ect.
*
Former Employers
List below last three employers, starting with most recent.
EMPLOYER #1
NAME OF PRESENT OR LAST EMPLOYER
*
ADDRESS
*
Line 1
Line 2
City
State
Zip Code
Country
JOB TITLE
*
START DATE:
*
LEAVE DATE:
*
MAY WE CONTACT YOUR SUPERVISOR?
*
YES
NO
NAME OF SUPERVISOR
*
SUPERVISOR PHONE NUMBER
*
DESCRIPTION OF WORK
*
REASON FOR LEAVING
*
EMPLOYER #2
NAME OF PREVIOUS EMPLOYER
*
ADDRESS
*
Line 1
Line 2
City
State
Zip Code
Country
JOB TITLE
*
START DATE
*
LEAVE DATE
*
NAME OF SUPERVISOR
*
MAY WE CONTACT YOUR SUPERVISOR
*
YES
NO
SUPERVISOR PHONE NUMBER
*
DESCRIPTION OF WORK
*
REASON FOR LEAVING
*
EMPLOYER #3
NAME OF PREVIOUS EMPLOYER
*
ADDRESS
*
Line 1
Line 2
City
State
Zip Code
Country
JOB TITLE
*
START DATE
*
LEAVE DATE
*
NAME OF SUPERVISOR
*
MAY WE CONTACT YOUR SUPERVISOR
*
YES
NO
SUPERVISOR PHONE NUMBER
*
DESCRIPTION OF WORK:
*
REASON FOR LEAVING:
*
REFERENCES
List professional references whom we may contact
REFERENCE #1: NAME, ADDRESS, BUSINESS, PHONE #
*
REFERENCE #3: NAME, ADDRESS, BUSINESS, PHONE #
*
REFERENCE #2: NAME, ADDRESS, BUSINESS, PHONE #
*
ADDITIONAL INFORMATION
If there is any additional information you would like us to be aware of when reviewing your application, please include in the box below:
Comment
*
AUTHORIZATION
"By clicking the 'SUBMIT APPLICATION' button below, 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 my 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 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.
I understand that a criminal records check may be necessary prior to my employment. If such reports are required, I 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 from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment. "
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.
In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.
TYPED NAME - electronic signature
*
DATE
*
Submit Application
Vegan, St. Louis, yoga, nutrition, raw, cafe, vegetarian
