Application for Employment ‘PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER Personal Information are rie AT Nae FST SOCAL SECURIT RESET AOORESS lar SATE = Fao ERINENT ADORE lar SATE FOOD RONEN, SECOHOARY PHOHENO REFERRED Employment Desired —— Fosmion BATE YOUCANSTART BMART OESTED fae vou 1F 90, MAY We BGURE OF ARE YOU LEGALLY AUTHORED urvores wow []ves []xo | Younpmesevreurvoverr []ves []vo | toworkin meus? Cs [) reer paren ins couravrseroner [_]ves [_]no Education History. _ Cree HGH SCHOOL coLLece TRADE, eusINESs, OF | (CORRESPONDENCE ‘SoHo | General Information [Susvecr oF spec. [SrUDYMESEARCH WORK [SPEGALTRANING lsPECAL ALLS [US MacTARY OR NAVAL SERVICE aR Former Employers (usr 6c.0W Ast FOUR EMPLOYERS, STARTING WIT LAST ONE FIRS) wy Me sAtany | Po FOR LEAVING 08 ZZ To From 10 ART ‘008 Application for Employment NEEL EEREReferences (c1ve io THe NAMES OF TAREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNONWAT LEAST ONE YEAR) cs Authorization “1 cory thatthe facts contained in this application are true and compl to the best of my knowledge and understand that, if employed, falsitied statements on this application shall be grounds for dismissal, | authorize investigation of all statements contained herein and the references and employers listed above to give you any and all in- formation conceming my previous employment and any pertinent information they may have, personal or otherwise, and release the ‘company from all iablity for any damage that may result from utilization of such information. | 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, oro make any agreement contrary to the foregoing, unless its in writing and signed by an authorized company representative. ‘This waiver does not permit the release or use of disabilty-related or medtcal information In a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.” ORE SGRATORE Do Not Write Below This Line ome ITERVIEEDEY [REATIESS [GRARACTER [PensonAGTY oury sm ri Saar ia beer. POSTION RePont Waces APPROVED: UPLOT ENT MANAGER DEPARTWENT HEAD ‘SERERAL ANGER “Tis eppicaton for employment od ony for gnarl ue thoughout Unite Sats. TOPS assures no osponsbty and bere egltns any Iai forthe icuslon Ins frm of any quostons or equa or invorason Upen which aviator ot ea, state, andor esa aw may be based. Ris Te user's reeponsly to ersure at ‘tis fons uee comple wih sppicable avs, wich chenge rm ie ote.