Application for Employment

Pre-Employement Questionaire
An Equal Opportunity Employer

Applications are only kept on file for 45 days.

Personal Information

Name:   Social Security Number:
Current Address:   Apt #
City:   Are you 18 years or older?
State:   Phone:
Zip:   Email Address

Previous Address: Please list your last 3 addresses

Personal Information

Position When can you start?  
Are you employed now?      Salary desired  
Ever Applied to this company before?      When?  
Ever worked for this company before?      When?  
Reason for leaving
Name of last supervisor at this company      
Who referred you to this company?                

Education

School Level Name/location of school No of yrs attended Did you graduate? Subjects studied
High School
College
Trade, Business or correspondence school

Current or Former Employer

Name of present or last employer Phone No.  
Address City, State Zip  
Starting Date Leaving Date  
Job Title
Job Description
Reason for leaving

Former Employer

Name of present or last employer Phone No.  
Address City, State Zip  
Starting Date Leaving Date  
Job Title
Job Description
Reason for leaving

Former Employer

Name of present or last employer Phone No.  
Address City, State Zip  
Starting Date Leaving Date  
Job Title
Job Description
Reason for leaving

References (please list a professional/business contact)

Name Business Address Phone Number Relation

Service Record

Branch of Service Discharge date/rank  
Have you been convicted of a crime within the last 5 years?           
Information pertaining to prior conviction record will not necessarily preclude you from consideration.
       
       

Pre-Employment Physicals and Drug Screening Required

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, the making of false statements on this application shall be grounds for dismissal. Supplying information not requested by this application may be grounds for rejection of the application. I also understand and agree that no employee of Certco, Inc has the authority to enter into any agreement for employment for any specified period of time unless it is in writing and signed by the pundit of Certco, Inc. By signing below, I authorize Certco, Inc to contact any references, former employers and employees and to investigate all representations made in this application. I release Certco, Inc from any liability arising from Certco, Inc collection and use of such information.”
Signature