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Application For Employment

Personal Information - Pre-Employment Questionnaire, An Equal Opportunity Employer

Name (first, middle, last)___________________________________
E-mail_________________________________________________
Present Address_______________________________Apt No._____
City______________________State____________Zip____________
Phone__________________________________

Permanent Address_____________________________Apt No._____
City______________________State____________Zip____________

Are you 21 years or older? Yes_____ No_____

Desired Employment
Social Security #______________________________
Position_______________________ Date you can start____________
Salary desired__________________ Are you employed now_________
If so, may we inquire of your present employer? Yes_______ No______
Ever applied to Enviromatic before?
If Yes, Where?_________________ When?_______________
Ever worked for Enviromatic before?
If Yes, Where?_________________ When?_______________
Reason for leaving__________________________________
Name of last supervisor at Enviromatic__________________________
Who referred you to Enviromatic_______________________________

Education
School level-name and address of school - Years attended-did you graduate? - Subject Studied.
High School________________________________________________
College___________________________________________________
Other_____________________________________________________

References
Below give the names of three persons you are not related to whom you have known at least one year.
Name, Address, Business, Years Acquainted, Phone #
__________________________________________________________
__________________________________________________________
__________________________________________________________

Service Record
Branch of service______________________________________________
Discharge Date___________________ Rank______________________

Have you been convicted of a felony within the last 5 years? ____________
(if yes explain - will not necessarily exclude you from consideration)
__________________________________________________________
__________________________________________________________

Do you have a valid drivers license? Yes___________ No___________
State issued___________ License Number______________________
(a Valid Drivers License is Required, and Driver
Must Pass Review by Our Insurance Company)

Former Employers (must list at least the last 5 years work history)
List below all previous employers starting with the most recent first.


Name of employer_________________________________________
Address_________________________________________________
City_________________________State___________Zip__________
Starting date__________________Leaving date__________________
Job title________________________________
Starting salary_________________Final salary___________________
May we contact your supervisor________________________________
Name of supervisor_________________________Title____________
Phone___________________
Description of work_________________________________________
Reason for leaving_________________________________________

Name of employer_________________________________________
Address_________________________________________________
City_________________________State___________Zip__________
Starting date__________________Leaving date__________________
Job title________________________________
Starting salary_________________Final salary___________________
May we contact your supervisor________________________________
Name of supervisor_________________________Title____________
Phone___________________
Description of work_________________________________________
Reason for leaving_________________________________________

Name of employer_________________________________________
Address_________________________________________________
City_________________________State___________Zip__________
Starting date__________________Leaving date__________________
Job title________________________________
Starting salary_________________Final salary___________________
May we contact your supervisor________________________________
Name of supervisor_________________________Title____________
Phone___________________
Description of work_________________________________________
Reason for leaving_________________________________________

Name of employer_________________________________________
Address_________________________________________________
City_________________________State___________Zip__________
Starting date__________________Leaving date__________________
Job title________________________________
Starting salary_________________Final salary___________________
May we contact your supervisor________________________________
Name of supervisor_________________________Title____________
Phone___________________
Description of work_________________________________________
Reason for leaving_________________________________________

Authorization

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, 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 specific period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authirized company representative."

Date_________ Signature_____________________________________