The Nehemiah Project

Nehemiah Project

Application for Employment

Pre-Employment Questionaire - Equal Opportunity Employer


Date: Monday, February 06, 2012

Personal Information

Last Name: First: MI:
Present Address: City: State: Zip:
Permanent Address: City: State: Zip:
Phone Number: Referred By:

Employment Desired

Position(s) Desired: Date You Can Start: Salary Desired:
You may contact my current employer
I have applied here before When? Where?
I can provide required proof of my eligibility to work Full Time Part Time Temporary Shift: 1st 2nd 3rd
Mornings Afternoon Evenings

Education History

Name and Location of School Years
Attended 		Graduated? Subjects Studied
High School
Undergraduate College
Graduate/Professional
Trade, Business, or Other

General Information

Subjects of Special Study/Research, Work or Special Training/Skills:
US. Military or Naval Science: Rank:

Former Employers (List below last four employers, starting with the most recent first)

Date
Month and Year 		Name, Address and
Telephone No. of Employer 		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

Additional information you would like to provide

Authorization

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand taht, 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 of medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws"

Your initials in the following box represent your agreement and electronic signature: