Application for Employment Pre-Employment Questionnaire Equal Opportunity Employer
For consideration of employment, please fill out all fields in the application and questionnaire sections.
 
Application
Personal Information
First Name  
Last Name  
Present Address  
City  
State Zip  
Permanent Address check if same as present  
City  
State Zip  
Phone Number  
Referred By  
Employment Desired
Position  
Date you can start  
Salary Desired  
Are you employed? Yes No  
If so, may we inquire of your present employer? Yes No  
Ever applied to this company before? Yes No  
Where?  
When?  
Education History
Name & Location of School Years Attended Did you Graduate? Subjects Studied
Grammar School to YesNo  
High School to Yes No
College to Yes No
Trade, Business or Correspondance School to Yes No
General Information
Do you have a CDL? Yes No  
Do you have large/heavy equipment experience?
Subjects of Special Study/Research Work or Special Training/Skills
U.S. Military or Naval Service
Rank  
Former Employers (list below last four employers, starting with the last one first)
Date
Month and Year		 Name Salary Position Reason for Leaving
From
To
From
To
From
To
From
To
References (give below the names of three persons not related to you, whom you have known at least one year)
Name Address Business Years Known  
 
 
 
                       

"I certify that the facts contained in the 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 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.

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."
Date (mm/dd/yy)  
If you would like to include your resume, please check this box
Please send your resume as an attachment to tracy@chipseal.net.
By checking this box, you verify that all the information above is accurate to the best of your knowledge