career

HiTech Pre-Employment Questionnaire

Personal Information:

Your First Name

Your Last Name

Present Address

Permanent Address (if different)

Email Address

Phone Number

Are you 18 years old or older? YES NO

Referred By:

Employment Needs:

Position

Date you can start

Education

High School
Name

Location

Number of years attended

Did you Graduate YES NO

College
Name

Location

Number of years attended

Did you Graduate YES NO

Subjects Studies

Other Schooling
Type of school

Name

Location

Number of years attended

Did you Graduate YES NO

Subjects Studies

General Information

Subject of special study or research work

U.S. Military/Naval Service YES NO
if yes fill in next three
   Service
   Rank
   Type of discharge

Have you ever been convicted of or pled guilty to a criminal offense other than a traffic violation? YES NO
if yes, please state the date(s) and place(s) of conviction(s) or pleading(s) and the nature of the offense(s)

Do you have any objections against working: (select all the apply)
Saturdays Sundays
Holidays Overtime
Nights

Past Employment
List below your last four employers,
starting with the most recent first.

Employer 1
Dates of employment (m/y)

Name & address of employer

Salary

Position

Reason for leaving

Employer 2
Dates of employment (m/y)

Name & address of employer

Salary

Position

Reason for leaving

Employer 3
Dates of employment (m/y)

Name & address of employer

Salary

Position

Reason for leaving

Employer 4
Dates of employment (m/y)

Name & address of employer

Salary

Position

Reason for leaving

READ THE FOLLOWING BEFORE SUBMITTING APPLICATION
By submitting this form (clicking submit query button) 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.

By submitting this form (clicking submit query button) I authorize investigation of all statements contained here in 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.

By submitting this form (clicking submit query button) I also 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 with or without prior notice.