(PRE-EMPLOYMENT QUESTIONNAIRE) (AN EQUAL OPPORTUNITY EMPLOYER) PERSONAL INFORMATION DATE SOCIAL SECURITY NAME SOhaee 5 - uaF a ar 4 PRESENT ADDRESS a a aH = | PERMANENT ADDRESS - ree a aE = | __PHONE No ‘ARE YOU 18 YEARS OA OLDEA? _Yes0_Noo ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED = _W THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS? Yes © NO = 1 EMPLOYMENT DESIRED | DATE YOU saLany __Posimion GAN START BESIRED IF 0 MAY WE INQUIRE: ARE YOU EMPLOYED NOW? OF YOUR PRESENT ENIPLOYER? _EVER APPLIED TO THIS COMPANY BEFORE? WHERE? wens i REFERRED BY | pity “DID YOU. EDUCATION NAME AND LOCATION OF ScHOOL | YEARS. | creABJates | SUBJECTS STUDIED GRAMMAR SCHOOL _ High IGH SCHOOL 5 couese B “TRADE, BUSINESS OR _ EOARESPONDENCE ‘SCHOOL. ~ GENERAL iy — SUBJECTS OF SPEOIAL STUDY OA RESEARCH WORK SPECIAL SKILLS (CTIVMIES. (CIVIC, ATHLETIC, ETC.) ‘XCLLDE OnGAwZATONS. THE NAME OF WHiGH NOTATES THE RAGE, CREED, GOL AGE, WARTTAL STATUS, GOLA OR NATION OF ORIGIN OF HS WEWGERE| US. MILITARY OF PRESENT MEMBERSHIP IN. _NAVALISERVICE : RANK NATIONAL GUARD OR RESERVES "This form has been revsed to comply withthe provisions of the Americans wich Disabites Act ‘nd the final regulations and incerpretve guidance grumlgatea by che EEOC on skiy 26. 1951, © ror 20s wo (CONTINUED ON OTHER SIDE) umamusa.FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIASD. wonrPalB year | __ NAME AND ADORESS OF EMPLOYER SALARY | POSTION | REASON FOR LEAMING FnoM 70 Fao 12 Fan 70 FROM 0 WHICH OF THESE JOBS DID YOU LIKE BEST? JHAT DID YOU LIKE MOST ABOUT THIS JOB? REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR, NAME ADDRESS BUSINESS cee ‘THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTS. (iin name of state) IF15 UNLAWFUL IN THE STATE OF “TD REQUIRE OF ADMINISTER A LIE DETECTOR TEST AS A CONDMON GF EMPLOYMENT OR ERBLOIVENT AV EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES ‘AND OWL LABILITY ‘Signe of apgar 1 CASE OF _EMERGENGY NOTEY TAWE TEERESS PHONE N- “| CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME CN THIS APPLICATION 1S TAUE ANO COMPLETE, AND | UNDERSTAND THAT IF ‘ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF | Alv EMPLOYED, MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME. IN CONSIDERATION OF MY EMPLOYMENT, | AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND | AGREE THAT Mt EMPLOYMENT AND COMPENSATION CAN'BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY'S OFTICN. | ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDMONS OF MY EMPLOYMENT ‘MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. | UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN iT'S PRESIDENT, AND THEN ONLY WHEN IN WRITING AND SIGNED BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OA TO MAKE ANY ‘AGREEMENT CONTRARY TO THE FOREGOING," DATE SIGNATURE ‘DO NOT WAITE BELOW THIS LINE INTERVIEWED BY DATE. REMARKS: NEATNESS ABILITY HIRED: Yes 0 No POSITION DEFT. SALARYIWAGE DATE REPORTING TO WORK APPROVE EMPLOI EFT SC MANAGE Sa ae are SSeS ET marie ese eet aes eas aU cae MNS Oa SSURONG AIO Rena ere ne cess nar