APPLICATION FOR EMPLOYMENT Page:tt7 a (Pre-Employment Questionnaire) (An Equal Opportunity Employer) PERSONAL INFORMATION: Date: Aa IS, 20) q Name Pca tha, A last Fist wile Social Security Number: Present Address:__1024 Eact Alpxuacle Aven v Permanent Address: 1924 Eack Alexander Ayenue Phone No:_ (2.4) ‘Are You 18 years old older? Yes No. X ‘Are you prevented from lawfully becoming employed in this country because of visa immigration status? Yes No EMPLOYMENT DESIRED: 5 7 postion: _Clache bateyoucon stat: May 20, 2014 lary Desited: isu Us Ace you employed now? Yes___ Noo_ if, Yes, may We inquire your present employer? Yes wX Ever applied to this company before? Yes__ No Referred by EDUCATION: Toray Grammar Schoot _Frenat / Rivera middle No.of ys attended WUD you graduate? Yes OX No righ scroot_ Merced) Nocotyrsattended 4 vid you graduate? Yes__No © College Schoo!: No. ofyrsattended___id you graduate? Yes__No GENERAL: specalstits Tntemedicde Spaaich Speanlag ability Are youbilingual? Yes No___" What language? EMPLOYMENT HISTORY: Date (Month/Year) ‘Name and address of employer: salary: Position: From To Reason for leaving: From To Reason for leaving: From Ho eee Pee Ee eee Reason for leaving: | AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. 1 UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IS CAUSE FOR DISMISSAL, FURTHER, | UNDERSTAND AND AGREE THAT MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PREVIOUS NOTICE. SIGNED: Tar. Pub DATE: Mary 1S, 20/9