Application for Employment / Pre-Employment Questionnaire / E.O.E.
COLLEGE / UNIVERSITY
TRADE SCHOOL / BUSINESS SCHOOL / CORRESPONDENCE SCHOOL
(MOST RECENT EMPLOYER FIRST)
EMPLOYMENT HISTORY CONTINUED
MEDICAL HISTORY SURVEY
PLEASE INDICATE YES OR NO IF YOU HAVE EVER OR CURRENTLY SUFFER FROM ANY OF THE FOLLOWING CONDITIONS:
IN THE PAST 10 YEARS, HAVE YOU BEEN:
LIST / DESCRIBE ANY OF THE FOLLOWING THAT APPLY:
LIST OF REFERENCES
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 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 or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant Federal and State laws.
IF YOU AGREE WITH THE ABOVE AUTHORIZATION STATEMENT, PLEASE TYPE BELOW: "YES, I AUTHORIZE"
Please leave this field empty.