Pre-Employment Questionnaire
Personal Information
*Last Name:
*First Name:
Middle Name:
Present Address:
City:
State:
PA
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code:
Permanent Address:
City:
State:
PA
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code:
Phone Number:
*Email:
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?
Yes
No
Are you 18 years or older?
Yes
No
Employment Desired
Position:
Date you can start:
Salary desired:
Are you employed now?:
Yes
No
If so may we inquire of your present employer?:
Yes
No
Have you ever applied to this company before?:
Yes
No
Where?:
When?:
Referred by:
Education
Grammar School / Location:
# of years attended:
High School / Location:
# of years attended:
Did you graduate?
Yes
No
College / Location:
# of years attended:
Did you graduate?
Yes
No
Subjects studied:
Trade/Business/Correspondence School / Location:
# of years attended:
Did you graduate?
Yes
No
Subjects studied:
Military or Naval Service:
Rank:
Present membership in National Guard or Reserves?
Yes
No
General
Activities: (Civil, Athletic, Ect.)
(Exclude organizations of which indicate race, gender, creed, sex, age, marital status, color, or nation of origin of its members.)
Have you ever been convicted of a felony?
Yes
No
Have you ever been convicted of a sex crime?
Yes
No
Month & Year
Name & Address of Employer
Salary
Position
Reason for Leaving
Which of these jobs do/did you like best?
What did you like most about this job?
References:
Give the names of three people not related to you, whom you have known at least one year.
Name
Address
Business
Years Acquainted
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