Application for Employment Personal Information PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER ox NAME LAST NAME FIRST) ane REGENT ADDRESS anv Sm erENT ARTES av ame OMENS ECONOTAT IGNETO aerERREDET : Employment Desired Fosmot SREVOUSNSTAT ARE YoU EMPLOYED NOW? Ces Eso 1-80, MAY We INQUIRE (OF YOUR PRESENT EMPLOYER? EVER APPLIED TO arr Friis CoMParY BeronE? Clves No TREN Education Histor, High scHOOL couece TRADE, BUSINESS, OF (CORRESPONDENCE SCHOOL General Information [SURUECT OF SPECIAL [SrubymeseAneH Wore [SPECIAL TRANG SPECIES _ 10S. MiLTTARY OR [Rank — hisidlstace Former Employers ust 9e.01 Last FOUR EMPLOYERS, STARTING WIT LAST ONE FIRST zi SAME & ADDRESS OFEMPLOVER ce CONTINUED ON OTF SEReferences (cive se.ow THe Naues OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWNAT LEAST ONE YEAR) Authorization “tceriy thatthe fects contained inthis application are true andl complete to the best of my knowledge and understand that, it employed, falsified 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 concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from al ably for any damage that may result from uilization 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 specitied period of time, oF to make any agreement contrary tothe foregoing, unless it isin wing and signed by an authorized company representative. This waiver does not permit the release or use of disabilly-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and stato laws, | understand that a consumer recit roport or eriminal records check may be necessary prior to my employment. I such reports are requited, | understand that, in compliance with federal lav, the company wil provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to those reports. | also understand that a poor crecit history or conviction will not automatically result in disqualification from employment.” ‘in compliance with federal law, all persons hired will be required to verity identity and eligibility to work inthe United States and to com plete the required employment eligibility verification document form upon hire. one SIGNATURE! Do Not Write Below This Line one Remarks. RERINESS [GHARACTER PERSON eure are FoR POSTION a Derr, REPORT ‘APPROVED: DEPARTIIENT HERD ‘GENERAL HANGER EUPLOVIENT MANAGER ‘This aplaton for employments el ty fr general uso throughout he Unied Stats. TOPS assumes ro responstity and hereby las an fab fr the ineuion is eis form of any su sons of oquass er ifrmaton use wien avatar o! ea sao, analr egal ian may bo basa. his house's respons eraute at Tis fern use copies wih apptcabo awe, wich chara hom mo ta ie.